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AUTUMN 2003 

— ^ 






- r 


Neurobiologists illuminate 
our instincts for the arts 






John Ende 

1 930), along with Frederick 
Robbins '40 and Thomas 
Weller '40, won a Nobel Pri 
in 1 954 for discovering how 1. 
grow polio virus in the labora- 
tory, o breakthrough that paved 
the way for the development 
of a vaccine for the terrifying, 
ancient disease. In this issue, 
Weller memorializes Robbins, 
who died earlier this year. 

A L' T U M N 2 3 • \' O L U M E 7 7, NUMBER 2 



Letters 3 

Pulse 5 

\ewly created and newly honored: 
buildings, classes, departments, 
magazines, centers, and geniuses 

President's Report 9 

h\ Eve]. Hig^mhotham 

Bookmark 10 

A review by Elissa El\- of The Mcmorx 
Cure: How to Protect Your Brain Against 
Memory Loss and Alzheimer's Disease and 
Everything You Never Wanted Your Kids to 
Know About Sex (But Were Afraid They'd Ask) 

Bookshelf 11 

Benchmarks 12 

Harry Potter lends his name to a gene 
that may hold the key to puberty. 

Class Notes 66 

InMemoriam 69 

Frederick C Rohhins 

Obituaries 70 

Endnotes 72 

A slow reader relies on quick wits to 
sur\-ive his third year of medical school. 
hv U illiam D. Cochran 


Light Vision 14 

\Vh\- do \ lonet's poppies stir in the breeze? Why does Mona Lisa's 
smile disappear, then reappear, as our gaze shifts? A neurophysiologist 
reflects on how our visual processing system affects our perceptions of art. 


The Incurable Disease of Writing 24 

Some writers struggle tor days to compose a single sentence, while others 
scribble deep into the night, seemingly unable to stop. A neurologist 
reflects on the compulsions and frustrations of literary creativity, 
an in(cr\'ievv vvitli Alice Flaherty 

The Defiant Muse 32 

A patient turns to poetry to try to preserve the memories he is fast 
losing to disease, by rafael campo 

The Sound of Music 

Ln unravelmg the puzzle of how music affects the brain, 
neurologists may help broaden music's healing potential 



Cover image: Meditating Philosopher, by 
Rembrandt van Rijn, courtesy of Reunion des Khisces 
Klationaux/Erich Lessing, Art Resource, New York 

Banishing Act 46 

A surgeon returns to Vietnam to exorcise war 
memories — and to Lift a stigma of birth from a new 
generation of children, by g e r a l d c o l m a n 

Visions of Nature 54 

An ophthalmologist reveals an eye for detail 
in the wild. fcvjAMEs d. brandt 

Witness to the Execution 60 

Tramed to preserve lives, a physician grapples 
with the execution of a friend on death row. 

by A N D R E W G . DEAN 

Harvard Medina] 


In This Issue 


fire and chatted with Bette, a friend whose tastes are on the hiigh 
end of literary. Thinking that I had some passing acquaintance v\ith 
chemistry, an impression my professors at HMS would have been quick to 
refute, she asked a httle sadly whether it spoiled the fire for me to know what 
was happening in it, whether information turned the mystery into materialism. 
The question astonished me then, and it does now. Even granting that fires are 
too complex really to comprehend, the little I knew about \'aporization and 
oxidation hardly detracted from the beauty of the moment and certainly did 
not diminish my sense of wonder, which is what I think she feared from the 
incursion of science into aesthetics. 

A common romantic heresy is that information makes us jaded; it is some- 
times expressed as the fear that children will lose their sense of wonder if they 
are educated. But it seems to me that children dorit come equipped with an 
innate sense of wonder. They take experience at face value and rarely bother to 
ask why things are as they are, and not some other way. (Toddlers' incessant 
"why" questions are really an effort to figure out what kind of answer they will 
get when they use the word "why" and are in the same \ein as questions about 
how to work the remote control.) The sense of wonder, as opposed to opera 
tional curiosity, is generally an adult prerogative, for it takes a lot of knowledge 
to be felt at all deeply. 

I think my old friend might be not merely saddened but appalled by this 
issue of the Bulletin, which explores the neurobiology underlying some aspects of 
painting, literature, and music. It is one thing to think that kno\\'Lng the chem 
istry of cadmium yellow or the physics of a string under tension will make an 
aesthetic experience — the painted image of an urban sunset, the sound of eight 
cellos and a soprano — less transcendent. That's bad enough. But when you turn 
to the brain, as some of the neurobiologists featured in this issue do, and find 
that the sublime appreciation for a Bach fugue or Monet's brush-stroked pop- 
pies appears to be an outgrowth of basic primate wiring diagrams — circuitr)' 
that seems to be about acquiring meat with the cooperation of one's nearest and 
dearest, or about not becoming meat to a stranger — I can hear Bette say, "Spare 
me the details." I dorit agree, but, then again, I never did. 


}^\ IM 


William Ira Bennett '68 


Paula Brewer Byron 


Beverly Ballaro, PhD 


Susan Cassidy 


Elissa Ely '88 


Judy Ann Bigby '78 
Rafael Campo '92 

Elissa Ely '88 

Atul Ga\\-ande '94 

Robert M. Gold\\yn '56 

Petri Klass '86 

N'ictoria McEvoy '73 

James J. O'CormeU '82 

Nancy E. Oriol '79 

Eleanor Shore '55 

John D. Stoeckle '47 


Laura McFadden 


Eve J. Higginbotham '79, ptesident 

Joseph K. Hurd, Jr. '64, president-elect I 

Steven A. Schroedcr '64, president-elect 2 

Paula A. Johnson '85, vice president 

Phyllis I. Gardner '76, secretat)' 
Kathleen E. Toomey '79, treasurer 


Nancy C. Andrews '87 

Gerald S. Foster '51 
Donnclla S. Green '99 
Lmda S. Hotchkiss '78 
Katherinc A. Keeley '94 
BarbaraJ. McNeif'66 
Laurence J. Ronan'87 
Mark L. Rosenberg '72 

Kenneth I. Shine '61 


Daniel D. Federman "53 


Nora N. Nercessian, PhD 


Joseph K. Hurd '64 

The Han'Ord .Medical Alumni Bulletin is 

published quarterly at 25 Shattuck Street, 

Boston. \\.\ 02115 '' by the Harvard 

Medical .Alumni .Association. 

Phone: (617) 384 8900 • Fax: (617) 384-8901 


Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 





4 4 It is hard to imagine anything more expensive 
to medical care budgets — and more profitable 
^ to pharmaceutical companies — than inter- 
B minable treatment with drugs that dorit work." 



Sacrificial Rites 

Congratulations on the fine special 
report on money and medicine, "Dorit 
Fence Me In," in the Spring 2003 issue of 
the Bulletin. Medical care has indeed 
become an intrinsically valuable com- 
modity, and I would like to offer an addi 
tional perspective on this. 

During the first seven years of my Me, 
my grandfather, as a member and chair- 
man of the .American Medical Associa- 
tion's Council on Medical Education, 
labored mightily to strengthen the role 
of scientific research in medical training 
and practice. The fundamental rituals of 
science helped elevate physicians, who 
became the only health professionals with 
the legal authority to prescribe the thera- 
peutic drugs produced by this science. My 
grandpas efforts were successful. Today's 
highly de\'eloped procedures — such as 
FDA approval, medical training, and stan- 
dards of practice and licensing — are insep- 
arable from their roots in scientific ritual. 

Today's approved treatments are those 
that have been proven to help most people 

with a particular pathology, typically 
about two- thirds. The fact that the same 
research has t}'pically shown that a third 
of patients tend to fail to benefit seems to 
have shpped through the cracks. Today's 
rather inflexible rituals of practice require 
prescribing only those treatments that 
ha\e been scientifically proven to help 
most people, whether they help a specific 
patient or not. Perhaps not in academic 
settings, where such things are more 
closely scrutinized, but assuredly in gen- 
eral throughout the nation, this is so. 

It is hard to imagine anything more 
expensive to medical care budgets — and 
more profitable to pharmaceutical com- 
panies — than interminable treatment 
with drugs that don't work. Our rituals 
are no longer serving their original pur- 
pose of ensuring purity of practice. I do 
not see how either financial reform or 
tighter regulation of practice can have 
much benefit without changing the ritu- 
al (which is, admittedly, extraordinarily 
difficult to do). The beneficial change 
that I envision is simply to bring about 

the inclusion, in the poUcy and standards 
of practice books, both procedures for 
identifying those individuals not being 
helped by the standard approved treat- 
ments and procedures for selecting alter- 
native treatments for them. 

Many physicians would love to do 
just that, but have been restrained by 
the absence of necessary policies, proce- 
dures, and standards of practice autho- 
rizing them to do so without jeopardiz- 
ing their pay and position. 

In mid-career, I became aware that, as a 
graduate of HMS, I was looked upon with 
some suspicion as having come from a 
school where students learned to think 
for themselves and to apply scientific 
principles in their true sense, not just fol- 
low estabhshed protocol for its own sake. 
I am grateful that this appears to be so. 


Dollars and Sense 

In 'A Fistful ot Dollars," in the spring 
issue of the Bulletin, the panel, incredibly, 
failed to notice the elephant in the 
living room. The pre-eminent cause of 
our health care system's malaise — not 
addressed by the panel — is private insur- 
ers' pursuit of corporate profit. This is a 
prime reason why half of the $1.6 trillion 
a year we spend on health care goes to 
health care business, not health care ben- 
efits. This is the reason that up to 25 per- 
cent of private insurers' premium income 
goes to advertising, administration, mega 
executive salaries, and profit, while 
Medicare's overhead is under 3 percent. 
This is the reason we spend two to three 
times as much on health care per capita as 
any other industrialized country and yet 
we, alone, have 43 nuUion mostly work- 
ing citizens with no health insurance. 
This is why Americans covered by pri- 
vate, employer-based insurance are 
restricted in their free choice of doctor 
and hospital and why their doctors' 
autonomy has been decimated. This is the 
reason the World Health Organization 
ranked our inefficient, absurd, and cruel 




system 37th in the world in 2000. In the 
category of "fairness," we ranked 54th. 

While the panel did not see the ele- 
phant, they did see the solution as more 
complex than it needs to be. Once we stop 
treating hcLilth care as a free-market com 
modify and treat it as a societal obhgation, 
our solution would be the same one 
accepted by all other developed coun- 
tries in their various, generally popular, 
government-run systems. And we would 
save money, too. An improved Medicare 
for all would sa\'e billions by spreading the 
risk to the young and healthy, not just the 
old and sick. Further huge saxings — hun- 
dreds of billions, says the Congressional 
Budget Office — would be realized by elim- 
inating adx'ertising, marketing, and profit 
and by vastly simplifying administration. 


The panel worried about the prospect 
of long waits for non- emergency care as in 
some other nations. But, as noted, other 
countries spend far less on health care than 
we do. Dr. Marcia AngeU stated it well in a 
New York Times op-ed piece in October 
2002: "If they were to put the same amount 
of money as we do into their systems, there 
would be no waits. For them, the problem 
is not the system; it's the money. For us, it's 
not the money; it's the system." 

Since organized medicine was repre- 
sented on the panel, a more rounded dis- 
cussion would have occurred had you 
included a leader of the national Physi- 
cians for a National Health Program, sev- 
eral of whom are in the HMS community. 


Mass Appeal 

I would like to express my deep appreciation to Farrokh Saidi '54 for his 
kind words about my father, Robert "Hawk" Shaw '45, in Dr. Saidi's account 
about the gripping challenges he has faced since his return to Iran to practice 
medicine (Spring 2003 issue). Dad always spoke of 
Dr. Saidi with the strongest admiration and affection. 

I also wanted to mention that in editing Dad's 
obituary for publication in that same spring issue, the 
Bi(//cf!)i got the story slightly wrong — Hawk's first 
wife, Laura ("Cricket"), did not survive him. She died 
in August 1998, which prompts me to launch, Dad- 
like, into a possibly true story about two of our 
founding fathers. Thomas Jefferson and John Adams 
were fast friends in their revolutionary youth, but in 
1800 they had a grave falling out after the bitterly 
contested presidential election ended with Adams 
stepping dowTi as U.S. president after one term, and 
Jefferson taking his place. The ice thawed between them about 12 years later. 
But old competitions die hard. One version of the story says that, in their 
final years, each of these last two surviving founding fathers \'owed he would 
outlive the other. In fact, both died on Independence Day 1826, Jefferson just a 
few hours before Adams. But Adams didn't get the news in time to sa\'or his 
short victory. His last words are said to have been, "Thomas Jefferson sur\'i\'es!" 

This story is particularly appealing to Hawk and Cricket's children, who 
suspect those two also had an unspoken competition to outlast the other. Dad 
won the competition hands down, but it appears fate gave Mom a paper victo 
ry this spring in the Bulletin. 

Robert "Hawk" Sha>v 



1 wanted to compliment you on the 
excellent spring issue. I can't tell you 
how much I look forward to receiving 
the Bulletin with its fine articles and the 
news about my friends at Massachu- 
setts General Hospital in the '40s, '50s, 
and '60s. I was saddened to read about 
the tragic deaths of Dr. and Mrs. Arthur 
Guyton '43A after the wonderful write- 
up about them that appeared in just the 
previous issue. Thank you, again, for 
doing such a great job. 


The Bald Truth 

I enjoyed reading "Heavy Metal," Don- 
ald Bickley's interesting collection of 
stories in the Spring 2003 issue of the 
Bulletin. As a dermatologist, I was partic- 
ularly intrigued by the thallium story, in 
which Dr. Bickley describes a group of 
young women who permanently lost 
their scalp, eyebrow, and eyelash hairs, 
presumably as a result of using a depila- 
tory cream containing thaUium acetate. 

That story prompted me to remember 
that during my dermatology residency, I 
had read that thalhum was at one time 
used therapeutically to cause depilation 
in patients with tinea capitis. Several of 
my old textbooks confirm that history. In 
addition, both Moschella's Dermatolog}' 
(1975) and Rook's Textbook ofDeimatolog}'. 
Third Edition (1979), state that the hair 
loss due to thallium is reversible, unlike 
the situation with Dr. Bickley's patients. 
Perhaps his patients' hair loss was not 
caused by the direct toxic effects of the 
thallium in the cream they used. 


The Bulletin welcomes letters to the editor. 
Please send letters h\ mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston. 
Massachusetts 02115): fax (617 3S4-S901): or 
email (hulletin(<Phms.har\' Lcttas may 
he edited for length or clarity. 




A Towering Investment in Science 


k^^Afl in the distance — and provid 
^TiTB ing the only \-isible reminder 
of almost three years of 
traffic stopping construction — Har\-ard 
Medical School's new research building 
at n Avenue Louis Pasteur was officially 
unveiled on September 24. The speed 
with which the massive endeavor was 
carried out, and the elegance of its final 
product, call to mind another famously 
efficient project — the mapping of the 
human genome. 

It was the human genome project, in 
fact, that had inspired HMS dean Joseph 

Martin and a quorum of colleagues to 
propose the new building in the first 
place. "We wanted to take ad\'antage of a 
unique moment in the life sciences," Mar- 
tin said. With the human genetic map in 
hand, researchers around the world ha\e 
been racing to find genetic causes and 
cures for a \'ariet}' of human illnesses. To 
jump-start that quest, Martin and his col- 
leagues had the idea to gather researchers 
from the clinical and basic science worlds, 
including the Departments of Pathology 
and Genetics, under one roof. 

The architects clearly took the theme 
of collaboration to (conrinucd on page 6) 


The newest members of the 
HMS community — the Class 
of 2007 — donned their white 
coats in August. The class is 
51 percent women and 49 
percent men. Twenty-one 
percent of the students ore 
Asian Americans, 16 percent 
African Americans, 10 per- 
cent Latinos, and 2 percent 
Native Americans. The class 
includes representatives of 
33 states, plus the District of 
Columbia, and 12 foreign 
countries: Brazil, Canada, 
the Dominican Republic, Ger- 
many, Greece, Haiti, India, 
Jamaica, Kenya, Mexico, 
Nigeria, and Taiwan. Ten 
members of the class ore 
MD/PhD students. 

The youngest entering med- 
ical student is 21 years old, 
the oldest is 32, and the 
median age is 23. Roughly 
two-thirds of the class majored 
in the sciences while under- 
graduates; 1 percent majored 
in the social sciences, 10 per- 
cent in the humanities, and 
1 3 percent in other majors 
and/or double majors. ■ 

RITE STUFF: After receiving his 
white coat, Matthew McCarthy 
'07 is congratulatecJ by Augustus 
White, Holmes Society master. 

ON COMMON GROUND: The new research building will invite researchers and 
clinicians to collaborate In the search for genetic causes and cures. 



YIELD OF DREAMS: The new building 

(continued from pa^c 5) 
heart. From its revealing glass fagade, 
which draws in even the casual passer- 
by, to its expansive, open-plan labora- 
tories and wood paneled hallways, dot- 
ted wath nooks, plazas, and gardens, the 
building seems to be one big invitation 
to come explore. The half-million- 
square-foot structure, with a price tag 
of $260 million, includes a ten-story 
tower looming above a four-story 
wing facing Avenue Louis Pasteur. 

"We sought to make the building a 
part of, not a satellite of. Harvard Med- 
ical School and its teaching hospitals," 
Martin said. "Many researchers and 
clinicians will join hands and forces 
here to \\'ork on the mission of alleviat- 
ing human suffering caused by disease." 

Lawrence Summers, president of 
Harvard University, expressed pride 
in the new endeavor and high hopes 
for its mission. "As a consequence of 
what happens in this building," he 
said at the ribbon- cutting ceremony, 
"many, many people at this university, 
in this city, in this country, and in the 
world will be far better off." ■ 

Mistfl Landau is the senior science writer 
for Focus. 

A Systematic Approach 



announced the creation of the 
Department of Systems Biolo- 
gy (DSB), one of the first 
department-level systems biology pro- 
grams in the nation. Systems biolog)' seeks 
to build from current knowledge of genet- 
ic and molecular function to an under- 
standing of how a whole cell works as a 
system, and from there to an understand 
ing of multicellular systems. 

The DSB will be the first completely 
new department at HMS in more than 
20 years and, with more than 20 faculty 
recruitments expected, will be one of 
the School's largest. The first chair of 
the new department. Marc Kirschner, is 
a pioneering cell biologist who led the 
1993 formation of the School's Depart- 
ment of Cell Biology and in 1999 helped 
create the Harvard Institute for Chem 
istry and Cell Biology. 

"As we understand more about the tini- 
est pieces that we are made of, it becomes 
increasingly clear that we do not under- 
stand how they work together as sys 
tems," Kirschner says. "We need to build 

on the foundation of molecular biolog)' to 
construct an understanding of the archi- 
tecture of the ceU and how cells cooperate 
across organ systems, with a predicti\'e 
model of physiology as the ultimate goal." 

Two other founding facult)' members 
have been named; Timothy \htchison, the 
Hasib Sabbagh Professor of Systems 
Biology at HMS, and Lewis Candey HMS 
professor of medicine at Beth Israel Dea- 
coness Medical Center. The department 
wiU consist of newly recruited faculty 
from such areas as mathematics, computer 
sciences, physics, and engineering, as well 
as from traditional biomedical fields. 

The department wiU focus on educa- 
tion and wlU provide a learning emiron- 
ment to facihtate training the systems 
biologists of the future. "We hope this 
wUl become a model for other depart 
ments in medical schools and colleges 
across the country," says Joseph Martin, 
dean of HMS. "Biologists will need broad 
training in quantitati\'e science, and phys- 
ical scientists need to be exposed to new 
approaches to biology that make use of 
their talents and experience." ■ 


The 75th anniversary issue of the Bulletin 
recently received several national honors: a 
gold medal Eddie Award from Folio: Magazine; 
a Clarion Award from the Association for 
Women in Communications; and an Award 
of Distinction from the Association of 
American Medical Colleges. The most 
enduring honor for the 6u//ef/n, though, 
was having the 75th anniversary issue 
included in the time capsule created as 
part of the dedication of the New 
Research Building. ■ 



The State of the School 



School address in October, 
Dean Joseph \ lartin recapped 
"an extraordinary year" at 
HMS that saw the opening of the largest 
building e\'er constructed by Harvard 
University and the creation of the 
School's first totally new basic science 
department in 20 years. 

The e\'ents marking the dedication of 
the new research building "were really 
momentous for many of us," Martin said. 
"We have come to think about the struc- 
ture of Harvard Medical School as two 
Quads separated — but only shghtly — by 
Longwood A\'enue." 

Turning to the new Department of 
Systems Biology, Martin pointed out that 
"our investment in the formation of a 
new structure to house systems biology 
is a major departure from what has been 
done in most other institutions, where 
interdisciplinary or interdepartmental 
efforts have been made." 

Martin said that creating a depart- 
ment for systems biology — sometimes 
called "the new physiology" — in some 
ways represents a throwback to an ear- 
lier scientific era, with its renewed 
emphasis on organ systems and organ- 
isms as opposed to isolated genes and 
proteins. Pulling up a photo of the great 
HMS physiologist Walter Bradford 
Cannon, Class of 1900, Martin recalled 

that "when Marc Kirschner presented 
some of his ideas about this back in the 
winter, he referred to Walter Cannon, 
who, I think, probably turned over in 
his gra\e when we disposed of physiol- 
ogy ten years ago.. ..I think he would be 
pleased that we've returned to this as a 
focus of our efforts." 

Martin also welcomed Malcolm Cox 70, 
who arrived in May to become dean for 
medical education, and Jeffrey Newton, 

on leading the Channing Laboratory and 
the new biodefense and emerging infec- 
tious diseases initiative. 

Exemplifying the success of collabo- 
ration in the HMS community, Martin 
noted, is a $24-million grant from 
the Donald W Reynolds Foundation, 
establishing a cardiovascular clinical 
research center to develop new risk 
measures and biomarkers in atheroscle- 
rotic heart disease. The center will 
involve researchers from Brigham and 
Women's Hospital, Massachusetts Gen- 
eral Hospital, Beth Israel Deaconess 
Medical Center, and HMS. 

"We're very proud of that joint 
effort," Martin said. "It is not just a 
wonderful opportunity with a large 
amount of money, but it's an example 
of how collaboration can lead to a 
good endpoint." 

Turning to education, Martin out- 
lined recommendations of the curricu- 
lum reform task force and discussed the 
next steps in the multiyear process of 
revamping the School's medical educa- 
tion system. In addition to possible 

"Too often, the definition of what college 
science should be is focused around passing 
the MCAT to get into medical school." 

who joined the School as dean for 
resource development in August. Martin 
recognized several HMS leaders who 
have assumed new responsibilities in the 
recent administrative reorganization: 
Nancy Andrews '84, as associate dean for 
basic science and graduate studies; 
Raphael DoUn '67, as dean for academic 
and clinical programs; and Jules Dien- 
stag, as associate dean for academic and 
clinical programs. Martin led a round 
of applause for Dennis Kasper, who 
stepped dowTi after six years as execu- 
tive dean for academic programs to focus 

changes in the curriculum itself, one 
recommendation — spurred in part by a 
National Academy of Sciences report — 
is to review and possibly revise admis- 
sion requirements to ensure that incom- 
ing students are well prepared. 

"One concern expressed in the 
report is that too often, the definition 
of what college science should be is 
focused around passing the MCAT to 
get into medical school," Martin said, 
"and this betrays what should be a 
broader interest in science at the col- 
lese level." ■ 





HMS will establish the New 
England Center on Biodefense 
and Emerging Infectious Dis- 
eases (CBEID) OS part of a 
strategic plan developed by 
the National Institutes of 
Health in the wake of the ter- 
rorist attacks and anthrax 
release in 2001. The CBEID 
will be one of eight regional 
centers that will develop inter- 
ventions against nnicrobes that 
can be used as bioweopons, 
as well as emerging infections 
such as West Nile and SARS. 

The CBEID will support nine 
programs focusing on basic 
research and development of 
vaccines and therapeutics for 
the prevention and treatment 
of these diseases. Five of the 
programs will be based at 
HMS; the remaining four will 
be based at Boston University, 
the Center for Blood Research 
in Boston, the University of 
Massachusetts-Dartmouth, and 
the University of Massachusetts 
Medical School. 

Dennis Kasper, the William 
Ellery Channing Professor 
of Medicine at HMS, will 
serve as scientific director 
of the center. ■ 

Jim Yong Kim 

Catchers in the Rye 


U^H MacArthur "genius" grants 

for 2003, recently announced 
by the John D. and Catherine 
T. MacArthur Foundation, were two 
HMS alumni, Jim Yong Kim '86 and 
Nawal Nour '94. Each will receive a 
five-year, $500,000 award, with no 
strings attached. 

"Both Jim Kim and Nawal Nour have 
incredible track records for developing 
innovative programs for helping people 
who have generally slipped through the 
significant gaps in society's safety nets," 
says Joseph Martin, dean of HMS. "The 
HMS community has been quite proud 
of what Jim and Nawal have already 
accomplished and looks forward to what 
they can do with the assistance of the 
MacArthur Foundation." 

An HMS associate professor of social 
medicine and also of medicine at Brigham 
and Women's Hospital, Kim is on leave 
this year to work as a public health physi- 
cian at the World Health Organization in 
Geneva, specializing in the control and 
eradication of infectious diseases. He has 
formulated new models for containing 
multidrug resistant tuberculosis, a dis- 
ease that was once considered untreat- 
ablc in many poor regions around the 
world. Kim has envisioned and applied 
effective interventions at both local and 
global le\-cls and is currently mapping 

Nawal Nour 

new strategies for international health 
leadership in tuberculosis, AIDS, and 
other infectious diseases. 

Nour, who grew up in Eg)'pt and the 
Sudan, is an HNIS instructor in obstetrics, 
g^Tiecology, and reproducti\'e biology and 
the founding director of the African 
Women's Health Practice at Brigham and 
Women's Hospital. The only clinic of its 
kind in the United States, this practice 
addresses the medical and emotional 
needs of female immigrants who have 
been circumcised in their homeland. She 
has de\'eloped techniques for the surgical 
reversal of infibulation, the most se\'ere 
form of the practice. By apphing her skills 
in medicine and public health to contem- 
porary issues of culture and human rights, 
Nour is advancing initiatives in interna 
tional women's health. 

Previous recipients of the MacArthur 
"genius" grants include David C. Page 
'82 and Paul Farmer '90. Pa^e, a molecu 
lar geneticist and associate director of 
science at the Whitehead Institute in 
Cambridge, Massachusetts, received 
the fellowship in 1986 for his research 
on how genes on the sex chromosomes 
lead to male or female development. 
Farmer, the Maude and Lillian Presley 
Professor of Social Medicine at HMS, 
was granted a tellowship in 1993 for his 
work as a physician, anthropologist, 
and community health activist. ■ 



The Next Hundred Years 



the 100th anniversary of the groundbreaking of 
its original Quadrangle and dedicated the New 
Research Building on the recently dubbed 
North Quadrangle. Since the alumni have 
played a significant role in shaping the campus over the 
past century, we were invited to join the festivities for this 
most recent defining moment in the history of our alma 
mater. For those who were not able to attend, I ha\'e includ 
ed excerpts of my comments: 

Ln the fifth century BC, HeracUtus noted, "Nothing endures 
but change." Throughout its history, Harvard Medical School 
has courageously met the challenges of change, sometimes 
with ease and occasionally with hesitation, but always with 
a spirit of determination and strong leadership. As a way of 
marking this celebration, I invite you to join me on a brief 
journey into the past and a visionary peek into the future. 

tahzed student life at Harvard. Unkno\\ingly, the alumni had 
engineered the construction of the first building on what we 
now call the North Quad — Vanderbilt HaU. 

And so we celebrate the extension of the North Quad. 
xArchitecturally, this building embodies a new attitude for 
the School. In sharp contrast to the opaque, Greek- inspired 
marble exterior of the South Quad, the glass exterior of the 
new building bears witness to a spirit of collaboration and 
openness at HMS. It also reaffirms Dean Joseph Martin's 
symbolic reopening of the front door of Gordon Hall in 
1997. Scientific investigation can no longer occur in the soli- 
tude of a single laboratory, but must involve a symphony of 
investigators, even on a global level. By welcoming the 
warm rays of the sun within its walls, HMS also welcomes 
the community and helps ensure that the research con- 
ducted in the buUding remains relevant to the human con- 
dition. Once again. Harvard is responding to the challenges 

Scientific investigation can no longer occur in the 
solitude of a single laboratory, but must involve a 
symphony of investigators, even on a global level. 

As I began preparing these remarks while at home in Balti- 
more, we were being \'isited by a stormy young lady named 
Isabel. It was appropriately by candlelight, then, that I found 
myself rereading Nora Nercessian's centennial account of the 
Harvard Medical .Alumni Association, which began in I89I. In 
that monograph. Dr. Nercessian notes the critical involve- 
ment of the alumni in moving the campus from Boylston 
Street to Longwood Avenue, then a barren marshland. 

The first president of the Alumni Association, James Chad- 
wick, Class of I87I, reaffirmed the importance of the organi- 
zation in lifting the standard of medical education. He and 
others were instrumental in raising the necessary funds to 
construct this fortress of knowledge and investigation. He 
also reaffirmed the importance of the School as part of a larg 
er universit)', at a time when nationwide there was "a multi- 
phcity of independent schools with no high moti\'es." 

The alumm helped lead the needed reform in medical 
education. And when it was apparent that the young men of 
Harvard were having difficulty finding decent lodging in 
Boston, the alumni helped estabhsh the first medical school 
dormitory of its type in the country and the first realization 
of Har\'ard President A. Lawrence Lowell's vision for a revi- 

of a changing research landscape with determination and 
enlightened leadership. 

I can imagine a scenario 100 years from now in which HMS 
is dedicating the groundbreaking of its third international 
campus — located in Beijing, perhaps — and the president of 
the Har\'ard Medical Alumni Association is in attendance, 
representing not just 900 alumni as Dr. Chadwick did, nor 
8,800 as I do now, but more than 20,000 alumni, from such 
fields as stem cell and gene therapy, pharmacogenetics, and 
apphed nanotechnology. 

You may find that large number surprising, but keep in 
mind that the human life span wiU have expanded by 10 per- 
cent and that the continued efforts of HMS to recruit a diverse 
student population will have been extremely .successful. And 
when the time capsule is opened and the award-vvinning 75th 
anniversary issue of the Harvard Medical Alumni Bulletin is 
retrieved, undoubtedly someone will remark, "So those are the 
ones who shaped our medical past and enabled us to navigate 
the constant changes in our medical landscape." ■ 

EvcJ. Higginhotham 79 is chair of the Department of Ophthalmology 
at the University of Maryland School ojMedicme. 




Home Repair Books 
for Body & Soul 

The Memory Cure: How to Proteet Your Brain Against 
Memory Loss and Alzhcuner's Disease, by Majid Fotuhi '97 
(McGraw-Hill, 2003) 

Everything You Never Wanted Your Kids to Know About Sex 
(But Were Afraid They'd Ask), by Justin Richardson '89 and 
Mark A. Schuster '87 (Crown, 2003) 


body and soul. Enormous efforts go into writing them. 
They are meant to make our lives better, or at least more 
manageable. But advice books require time to read, lots of 
time — and lack of time is the broken light 
bulb most homes fail to fix. 

Take The Memory Cure, by Majid Fotuhi '97 
The magic claim comes on page three: "it's 
possible for you. have a perfect memory 
for life." Who could turn that down? 
Fotuhi, according to his bio line, "has the 
unique distinction of being both a faculty 
member in neurology at HMS and a neurol- 
ogy consultant at the Alzheimer's Disease 
Research Center at Johns Hopkins Hospi- 
tal." This will be good. 

For the patient reader, there follow sec- 
tions on stages and types of memory; one 
feels intelligent for knowing them. There are 
sections on the differences between age- 
associated memory impairment, mild cogni- 
tive impairment, and Alzheimer's dementia. 
There are sections on plaques, tangles, cholinergic ccU death, 
and the sequential deterioration of temporal, frontiil, and pari- 
etal lobes that occurs in Alzheimer's disease. For confused and 
despairing families just beginning the process of diagnosis, 
there is also a useful chapter on reversible dementias. 

At last, Fotuhi comes to his Memory Protection Plan; the 
401(k) of cogniti\'e sa\'ings. I read the ten steps, reflected with 
some disappointment (no magic), then summarized them for 
my mother, who sat reading the Sunday paper on a couch 
across the room. I told her Fotuhi's ad\ice: lower her blood 
pressure, control her cholesterol, check her B12 and homocys- 
teine levels, add antioxidants to her diet, pre\'ent skull injury, 
minimize sensory deficits, optimize exercise physically and 
mentally, socialize (promotes multi-lobe stimulation), and be 
happy (decreases Cortisol le\'els). I waited for her response. 

The target audience gestured for the book. I tossed it over. 
She glanced at the title and opened to the table of contents. 

"How long is it?" she asked. She could u,se a cure. 
"One hundred and seventy-seven pages," I replied. 
"Too long," she said, snapping the book shut. "Hand me 
the Times magazine section." 

With a different audience, on a separate topic, I tried to 
share another how-to book. Everything You Ne\'cr Wanted Your 
Kids to Know About Sex (But Were Afraid They'd Ask), by Justin 
Richardson '89 and Mark A. Schuster '87, is 379 pages long. 
Encyclopedically speaking, it is a fuU-alphabet tour of sexu- 
al development, parenting styles, and suggestions for 
unavoidable and pivotal situations through the life cycle: 
how to respond to early self- stimulation ("humping Bar- 
ney"), how to anticipate puberty, ho\\' to discuss sexually 
transmitted diseases and birth control, how to consider the 
logistics of permissive sexual acti\ity. These could be useful 
when a parent is caught blindsided — or is hoping not to be. 
The second-person tone is determinedly friendly and 
happy-go-lucky; these are guys you could 
teU anything to — the neighbor who keeps all 
secrets, the fa\'orite bartender. There are 
catchy study results — by three years old, 95 
percent of boys have the word for their 
penises, but only 52 percent of girls ha\'e the 
words for their \'aginas and \'ulvas; in a sam- 
ple of American children asked about the 
purpose of sex, not one child under nine 
included pleasure; American kids can 
explain the mechanics of procreation by 
ele\'en years old, EngUsh kids by nine, and 
Swedish kids by seven. 

There are simple wisdoms, too: "authorita- 
ti\-e parenting is about as close as science has 
come to offering a recipe for healthy kids," or, 
"nurturing your child's sexual development 
is no less bittersweet than any other aspect of 
her growing up." But all this is buried in many clever anecdotes 
about interactions between parent and child; by page 250, it's 
a httlc like looking at too many photos of someone else's fami- 
ly. Still, the intentions are clear, decent, and important. 

So I offered the book to a friend, a working mother with 
two kids rounding the corners of puberty. She glanced at its 
width, then handed it back as if it were hot. "Can they cut to 
the chase?" she asked. "Mothers don't have time to read." 

This is the essential problem. There is so much in this 
world we ought to know, think, prepare for, and practice to 
prevent. Doing so would make life infinitely better. But this 
same life, the one full of timesaxing technologies, has left 
most of us forlorn from lack of time by the end of each day. 
We are not free to read long and useful books. We have to 
wait for the tapes. ■ 

Ehssa Ely '88 is a lecturer on psychiatry at HMS. 





in OphtKalmic 
Plastic Surgerj' 

True mf 
Blue M 


The Mealing Art 

A Doctor's Black Bag of Poetry, 

by Rafael Campo '92 

(W. W. }^onon and Company, 2003) 

An advocate of tapping into tfie power of 

language to help people heal, Campo 
explores the strong medicine offered by 
a range of acclaimed poets, including 
William Carlos Williams, Mark Doty, 
and Audre Lorde. Campo reflects upon 
his patients' positix'e responses to "poet 
ry treatment" and suggests a biocultural 
model of illness that would integrate the 
needs of the body, mind, and soul. 

Pathologies of Power 

Health, Human Ri^i^/its, and the New War 
on the Poor, by Paul Farmer '90 
(University of California Press. 2003) 

In his 20 years as an anthropologist and 
physician in Haiti, Peru, and Russia, 
Farmer has witnessed the struggles and 
suffering of people confronting illness 
in extreme situations. He recounts their 
stories to promote a deeper understand 
ing of human rights, linking individuals 
to the larger picture of political and 
economic injustice. 


A Guide for the Therapist, the Patient, and 
the Victim, by Martin Kantor '58 
(Pracger Publishers, 2002) 

Kantor's book on the controversial sub- 
ject of passive- aggressive personality 

disorder provides detailed clinical 
descriptions of the passive-aggressive 
patient, the victims of passive -aggres- 
sion, and the interaction between the 
two. Kantor also describes a treatment 
approach using several therapeutic 
methods — psychodynamic, supportive, 
cognitive, behavioral, and interper- 
sonal — to help patients deal with anger 
in a healthier way. 

Community-Based Health Care 

Lessons from Bangladesh to Boston, echtcd 
by Jon Rohde '67 and John Wyon 
(Management Sciences jor Health, 2002) 

In this anthology, 36 of the world's 
leading health experts reflect on their 
experiences in poor communities 
worldwide. The contributors explore 
such issues as equity, health financing, 
home visiting, and community-based 
health information systems as they 
recount their attempts to improve 
health care in countries as diverse as 
India, Peru, Haiti, X'ietnam, and the 
United States. 

Complications in Ophthalmic 
Plastic Surgery 

edited by Brian G. Brazzo '92 (Springer, 2003) 

This new volume instructs surgeons on 
how to prevent and manage the most 
common and significant complications 
associated with ophthalmic plastic 
surgery. Contributions from a number 
of oculoplastic surgeons are organized 
into three parts — Cosmetic Surgery, 

Ptosis, and Lower Eyelid Manipula- 
tion — and each chapter includes sec- 
tions on evaluation, technique, and 

Swimming Lessons 

Keeping Afloat in the Age of Technology, by 
David Ehrenfeld '63 (Oxford University 
Press, 2002) 

Trained in history and zoology as well 
as medicine, Ehrenfeld examines the 
effects of environmental degradation on 
human potential and considers new 
developments in such areas as educa- 
tion, military weapons systems, and 
biotechnology. He reveals how corpo- 
rate economic practices affect the way 
we live, work, and relate to each other, 
and offers suggestions to help people 
remain connected to nature and to 
restore damaged communities. 

True Blue 

A Novel, by Jeffrey Lee '87 
(Delacone Press, 2003) 

The author, a family physician, has writ 
ten a novel for young adults that 
explores what it means to be different. 
When Molly, the new girl in school, 
meets Chrys, she's drawn to his quiet, 
mysterious manner. Soon the two 
become partners to try to win the 
school science competition, and an 
unlikely friendship develops. As they 
work on their project, they reveal 
secrets to each other and learn to value 
their ov\ti unique gifts. 




Harry Potter and the Changer of Secretions 


School of Witchcraft and 
Wizardry, Harry Potter dis 
covers a mysterious \\'orld 
filled with gigantic talking spiders, chess 
pieces that come ali\'e, and a slathering 
three-headed dog named Fluffy. Soon 
enough, he gains admission to an even 
more mystifying realm — puberty, one of 
the most perplexing stages in the human 
life span. Now researchers have identi- 
fied a gene, GPR54, that appears to play 
a critical role in the onset of puberty, and 
they've dubbed the gene Harry 
Potter after the boy wizard. 

Adolescence begins when the 
hypothalamus, at the apex of the 
reproductive axis, sends out 
sharp pulses of gonadotropin- 
releasing hormone (GnRH). 
Reproducti\'e biologists still ha\'e 
not pinpointed the molecular 
players that allow the hypothala- 
mus to transmit its puberty- 
inducing signal. But Massachu- 
setts General Hospital scientists, 
working with researchers at other 
institutions, have discovered that 
GPR54 appears to play a critical 
role in getting out the message. 

Stephanie Seminara, William 
Crowley, and colleagues were first 
alerted to the role of GPR54 when 
they discovered a mutant version 
of the gene in people with idio- 
pathic hypogonadotropic hypogo- 
nadism (IHH). Unless treated, males 
with IHH fail to virilize — their voices do 
not deepen and their muscles and testes 
do not enlarge. Females neither menstru- 
ate nor develop normal breasts. 

Working with colleagues at Paradigm 
Therapeutics, a small biotechnology 
firm, the researchers found that mice 
lacking the GPR54 homologue exhibit 
symptoms of IHH. So compelling is the 
story that the New England journal ofMcdi 
cine broke a longstanding pohcy of pub 
hshing only clinical research; the article 
appears in its October 23 issue. "This is 

the first time the Journal is pubhshing ani- 
mal data, a historic ev'ent," says Seminara, 
HMS assistant professor of medicine. 

The role of the GPR54 protein is to 
get the GnRH message out of the 
hypothalamus, rather than to synthe- 
size the hormone. Seminara and her 
colleagues found that mice lacking 
GPR54 have normal levels of GnRH 
in their hypothalami. When injected 
with exogenous GnRH, the mice's 
pituitary glands, the next step along 
the reproductive axis, responded. "So 

DECODING RING: Massachusetts General Hospital 
researchers — including, from left, William Crowley, 
James Acierno, Jr., and Stephanie Seminara — helped 
solve the mystery of a gene related to puberty. 

the problem," Seminara says, "is in 
either the processing or the release of 
GnRH from the hypothalamus." 

IHH patients can be launched into 
puberty by pulsatile GnRH injec 
tions — a method pioneered by Crowley, 
HMS professor of medicine, nearly 25 
years ago. The GPR54 discovery could 
lead to more sophisticated treatments 
for IHH and other diseases. "There are a 
number of disease models — relating to 
puberty, hormone-dependent cancers, 
endometriosis — where you either want 
to stimulate or, more often, dowTiregu 

late the reproductive axis," Seminara 
says, "and GPR54 might provide the 
first clue toward developing therapies." 
That such an important clue should 
lie with GPR54 would have struck 
many as unlikely a few years ago. Iden- 
tified in 1999, the associated protein 
was little understood, other than that it 
was a G protein-coupled receptor with 
an affinity for metastasin, a metastasis- 
suppressing ligand. "The literature 
about GPR54 was more in the cancer 
field," says Seminara. .And there it might 
have stayed had Yousef Bo- 
Abbas, a former postdoctoral fel- 
low in Crowley's laboratory, not 
discovered, in his native Kuwait, 
a Saudi Arabian family with a 
large pedigree of IHH. 

Seminara, Crowley, and their 
colleagues used genetic linkage 
analysis to scour the family's chro- 
mosomes for defective genes. The 
researchers narrowed their search 
to the short arm of chromosome 
19, then, using human genome 
maps, to a handful of genes. 
GPR54 caught their eye mostly 
because of the intriguing distribu- 
tion of its protein — it appeared in 
the brain, pituitary, and placenta. 
"It had a bit of an endocrine feel to 
it," Seminara says. 

As it turned out, GPR54 was 
defective not just in the Saudi 
family, but also in a parient that 
Seminara and her colleagues had seen in 
the clinic at Massachusetts General 
Hospital. They had begun experiments 
to figure out how the defect was dis- 
rupting this patient's sexual maturation 
when Seminara received a telephone call 
from Stephen O'Ralully, a member of the 
advisory board of Paradigm Therapeu- 
tics. The company had just produced a 
knockout mouse that reproduced many 
of the symptoms of IHH. "He said to me, 
'Stephanie, the mouse gene's human 
homologue resides in your region of 
chromosome 19,'" Seminara savs. "He 



did not say the name of the mouse gene 
and I did not say GPR54, but we both 
knew. It was a wonderhil moment." 

Not only did the mice reproduce 
symptoms of IHH, but their pituitary 
glands also responded positively to 
GnRH injections. It was only after the 
researchers dissected the mouse hypo- 
thalami that they found direct evidence 
of the GPR54 protein's possible role as 
exporter, rather than synthesizer, of 
GnRH. "We found the GnRH content 
of the hypothalamus was normal," 
Seminara says. "That was the most 
powerful element of the data." 

Many hormones are clipped and 
cleaved to reach their final form. It is 
possible that the mice's lack of GPR54 
may interfere with that process. "W'e 
do not know exactly what form of 
GnRH was sitting in the hypothalamus 
of the mice," Seminara says. "It is also 
possible that GnRH is processed com- 
pletely fine and is just not getting out." 

Seminara and colleagues will be 
exploring yet another intriguing 
option. Although the hypothalamus 
triggers puberty by sending out intense 
pulses of GnRH, lower levels are 
released all along. During embryonic 
development, waves of GnRH wash 
through the reproductive axis. They are 
greatly subdued soon after birth, but 
the pulses ne\'er completely disappear. 
"GPR54 could be invohed in the same 
system that is involved in the quieting 
of the axis after the first few months of 
life," Seminara says. "It could be 
invoh^ed in the pubertal reawakening 
of the reproducti\'e axis." 

Paradigm Therapeutics gave GPR54 
the nickname "Harry Potter" follow- 
ing its tradition of naming knockout 
genes after famous orphans. Yet it may 
be only a matter of time before further 
studies illuminate the precise role of 
this mysterious gene. ■ 

Misia Landau is the senior science writer 
for Focus. 


but new research indicates that three stages of waking and sleep time 
may determine how accurately motor-skill memories are recalled. The 
findings could help stroke and head injury patients more efficiently 
releorn how to walk, talk, and otherwise move. 

In the October 9 issue of Nature, Matthew Walker, an HMS instructor in 
psychiatry at Beth Israel Deaconess Medical Center, reports his investigation of 
motor-skill memory, in which eight groups learned finger-tapping sequences similar 
to a piano exercise. Each group had a different schedule for being awake, 
sleeping, and recalling the sequences. 

Working in collaboration with Robert Stickgold, an HMS assistant professor 
of psychiatry at the Massachusetts Mental Health Center, Walker analyzed how 
quickly and accurately the groups performed the sequences and noted that three 
stages were necessary for the best memory recall. He compares these stages to 
the different processes a computer goes through to establish a file. 

The brain first initiates a memory much as a computer creates a document file. To 
save the memory, the brain needs about six waking hours for processing. If the com- 
puter shuts down or the brain goes to sleep before the file is properly saved, it is lost. 

According to Walker, the second stage "is absolutely dependent on sleep in 
order to occur." During a good night's sleep, the brain edits the memory file and 
makes it more efficient. This editing process requires several hours of sleep. "If you 
don't get that full night's sleep, you may be shortchanging your brain of learning 
potential," says Walker. 

The final stage is the "recall phase," in which a saved, edited memory becomes 
usable. "After the memory hod been stabilized and enhanced, it once again became 
pliable so that it could be altered in the context of new ongoing experiences," Walker 
soys. This stage allows the brain to tweak and perfect previously learned skills. 

Walker says the lost stage may explain why some patients with posttraumatic stress 
disorder benefit from talking about their experiences. As the patients recall their 
traumas, their memories ore slightly altered. "Over time," he says, "there may be the 
chance for these patients to redefine their memories and make them less traumatic." ■ 

— Nicole Giese 



Louis Leroy found Monet's 
Impression, Sunrise "vague 
and brutal" and "v«^orse 
than anyone hitherto had 
dared to paint." 


Why do Monet's popples stir In the breeze? Why does Mono Lisa's smile 

disappear, then reappear, as our gaze shifts? A neurophysiologist reflects 

on how our visual processing system affects our perceptions of art. 

by Margaret Livingstone 


a new Paris show in the spring of 1874, he 
expected to see "the kind of painting one 
sees everywhere, rather bad than good, 
but not hostile to good artistic manners." 
Instead, he found a "hair-raising exhibi- 
tion" whose nadir was Claude Monet's 
Impression, Sunrise. Leroy pronounced the 
seascape "at once vague and brutal" and 
"worse than anyone has hitherto dared 

to paint." Despite his revulsion — and 
that of many of his contemporaries — 
history has acknowledged this paint- 
ing: from Leroy's sneering review came 
the name for the art movement Impres- 
sionism. But what made Leroy object 
so fervently? 

The answer may he in part with the 
painting's luminance, or perceived light- 
ness. The elements of visual art have long 



PRODIGAL SUN: The sun in Impression, 
Sunrise (top) appears so brilliant that it 
seems to pulsate. But a grayscale ver- 
sion reveals that the sun is actually no 
lighter than the background clouds. To 
the more primitive subdivision of our 
visual system, the sun appears almost 
invisible in the painting. In the bottom 
version, the sun has been made lighter 
than in the original — which is closer to 
the v^oy it v/ould appear in reality — and 
it nov«^ seems, paradoxically, less bright. 

been held to be color, shape, texture, 
and line. But an even more basic distinc- 
tion lies between color and luminance. 
Color can convey emotion and symbol- 
ism, but luminance alone defines shape, 
texture, and line. "Colors are only sym- 
bols," Pablo Picasso once wrote. "Reali- 
ty is to be found in lightness alone." 

Most people are comfortable talking 
about color. Yet luminance, even though 
it is more fundamental, is dimly under- 
stood. Given two patches of gray, it is 
easy to identify which is lighter, but 
given two colors, it is often difficult to 
draw such a distinction. 

A monochromatic rendering of 
Impression, Sunrise reveals that Monet 
painted the sun at exactly the same 
luminance as the gray of the clouds. If he 
had rendered it in a strictly representa- 
tional style, the sun would have been 
brighter than the sky by a factor too 
large to have been duplicated with pig- 
ments. If he had made the sun lighter — 
which is closer to the way it would 
appear in reality — it would have lost its 
quavering luminosity and would have 
seemed, paradoxically, less bright. 
Rather than appearing as a source of 
light, the sun would have looked like a 
cutout affixed to the clouds. By render- 
ing the sun the exact luminance as the 
sky, Monet achieved an eerie effect: his 
orange sun appears to pulsate across the 
grayish-green water. 

Gray Matters 

Color and luminance play distinct roles 
in our perception of art — and even of 
real life — because our visual systems 
analyze color and luminance separately. 
The areas of our brain that process infor- 
mation about color, in the temporal lobe, 
are several centimeters av\'ay from the 
areas that analyze luminance, in the 
parietal lobe. They are as anatomically 
distinct as vision is from hearing. 

The luminance system, which is evo- 
lutionarily older, is common to all mam- 
mals; the parts of the brain that process 
color information are present only in 
primates. That is probably why the most 
primitive visual information about a 
scene is found in variations of lumi- 
nance. It does not matter which color is 
used to convey the luminance signal, 
because the parts of our brains that ana- 
lyze the most basic features of a scene 
are, quite literally, colorblind. 

On a gross level, the \isual system is 
a single pathway in the brain. On a finer 
scale, however, this pathway consists of 
two major subdi\isions. The e\'olutionar- 
ily older large -cell subdi\1sion is respon- 
sible for our perception of motion, space, 
position, depth, figure-and-ground segre- 
gation, and the o\'erall organization of the 
visual scene. This subdivision is called 
the "Where" system. The small- cell sub- 
division, which is well developed only in 
primates, is responsible for our ability 
to recognize objects, including faces, in 
color and in complex detail. This newer 
system is called the "What" system. 

The Where and What systems differ 
not only in the kind of information they 
extract from the environment, but also 
in how they process light signals. The 
Where system is colorblind; the What 
system carries information about color. 
The Where system has a much higher 
sensitivity to small differences in bright- 
ness. It is also faster and more transient 
in its responses and has a slightly lower 
acuity, or resolution. In the retina, thala- 
mus, and early cortical areas, the Where 
and What systems are physically inter- 
digitated, yet they keep the information 
they process largely separate. At higher 
le\'els, the two subdi\'isions become e\'en 
more spatially segregated. 

Evolution likely accounts for these 
subdivided visual tasks. The Where 
system in humans and other primates 
resembles the entire visual system of 



BLACK AND BLUE: The melancholy blues in Pablo Picasso's The Tragedy (Poor People 
on the Seashore) carry the emotional content of the painting. But a black-and-white 
reproduction reveals that it is not the colors themselves but their luminance that 
makes it possible for us to recognize the figures, to perceive their three-dimensional 
shape, and to understand the spatial organization of the scene. 

lower mammals. These animals are much 
less sensitive to color than we are, and 
they can neither scrutinize objects nor 
accurately discriminate them on the 
basis of visual attributes. Instead they are 
sensitive to objects in motion, because 
things that move — whether prey or 
predator — are likely to be important. 

Also, because the primitive visual 
system must have been used to navigate 
through three-dimensional environ- 
ments, it had to have been able to 
process depth information and distin- 
guish objects from their backgrounds. 
As the more complicated primate visual 
system evolved, the original system 
was maintained, probably because it 
was simpler to overlay color vision and 
object recognition onto the existing sys- 
tem than it would have been to inte- 
grate the two. 

Artistic License 

In the first and most fundamental step of 
our visual processing, our retinal gan- 
gUon cells are excited by hght impinging 
on their receptive field centers. Notably, 
however, they are inhibited by light 
falling on the immediately surrounding 
region. The net effect is to record the 
relationship of "center" to "surround." 

Cells at the next stage of processing, 
in the thalamus, show a similar center/ 

surround organization, which makes cells 
at these early stages of the \'isual system 
sensitive to discontinuities in the pattern 
of hght falling on the retina rather than 
to the absolute level of light. Neurons 
respond best to sharp changes, rather 
than to gradual shifts in luminance. This 
wiring allows the Wsual system to ignore 
gradual changes in light and the overall 
level of the Qluminant, factors that are 
usually not important biologically. Many 
visual modalities — such as luminance, 
color, motion, and depth — exhibit 
greater sensitivity to abrupt than to 
gradual change. In each modality, this 
selecti\'ity is due to an underlying center/ 
surround organization. 

It makes adaptive sense for our visual 
system to be designed in this way because 
it is more efficient to encode only those 
parts of the image that have changes or 
discontinuities than to encode the entire 
image. The \'isual system in a sense com- 
presses images because it takes energy 
for nerve cells to signal; the fewer cells 
that signal, the more energy is conserved. 
Higher-level visual processing, such as 
object recognition, is essentially the end 
result of extracting the information con- 
tent of an image. 

Artists can take advantage of this 
quirk in our visual system to expand the 
apparent range of reflectances of paints. 
Although a real scene may contain a large 

spectrum of luminances, our visual sys- 
tem initially analyzes each part of the 
scene separately. So by introducing grad- 
ual changes in the background lumi- 
nance, for example, an artist can shift the 
apparent luminance of the foreground in 
the opposite direction. 

Tricks of the Light 

.Artists have been playing with luminance 
for centuries. In his 1632 painting Meditat- 
ing Philosopher, Rembrandt used variations 
in luminance to create an almost ethereal 
golden glow. If this were a real scene, the 
luminance of the window would likely 
be hundreds of times that of the upper 
reaches of the shadowy staircase — an 
effect nearly impossible to dupHcate with 
paint alone. The paint representing the 
window actually reflects only 15 times 
more light than the paint representing 
the shadows in the lower left corner of 
the painting, but we perceive the window 
section to be substantially lighter. 

FOOL'S GOLD: In Rembrandt's Meditating 
Philosopher, the paint representing the 
v/indov/ reflects only 1 5 times more light 
than the paint representing the shadows 
in the lower left corner, but v/e perceive 
the v/indovs^ section to be substantially 
lighter. By using a combination of grad- 
ual background changes and local abrupt 
changes in luminance, Rembrandt simu- 
lated a much larger range of luminances 
than his pigments could supply. 


Some of the color combinations the Impressionists used have so 
Httle luminance contrast that they create the illusion of motion. 

Rembrandt created another illusion 
by painting the philosopher's head on a 
darker background and the crosspiece 
of the window frame on a lighter back- 
ground. The head thus appears relatively 
light and the window frame relatively 
dark, even though the head is darker 
than the frame. We cannot easily per- 
ceive the differences in the backgrounds 
because they meld gradually into one 
another. By using a combination of grad- 
ual background changes and local abrupt 
changes in luminance, Rembrandt simu- 
lated a much larger range of luminances 
than his pigments could supply. 

Over the centuries, artists continued 
to increase their command of luminance 
to enhance their ability to represent 

depth on a two-dimensional canvas. 
This trend toward representationalism 
reached a pinnacle in the early nineteenth 
century with the work of Jean-Auguste- 
Dominique Ingres, whose paintings have 
an amazingly photographic quality. Art 
historians have suggested that Ingres 
must have used a camera lucida or other 
optical aid to project an image of the 
scene onto the canvas or drawing tablet, 
so uncannily does he capture the grada- 
tions of luminance in his subjects. 

Then, toward the end of the nine- 
teenth century, the Impressionists 
aligned themselves against the represen- 
tational style of art epitomized in the 
work of Ingres. Some experimented with 
color and luminance, sometimes using 


PHOTO FINISH: In many of his paintings, such as the Comtesse d'Haussonville, 
Ingres took the command of luminance to a nev/ level, with more detail in the 
shado>vs of his paintings than in some of the sharpest photographs. 

unrealistic color gradations or abandon- 
ing luminance differences entirely. 

Still Lifes in Motion 

One of the Impressionists' most novel 
accomplishments is the shimmering, 
alive quality they achieved in many of 
their paintings. The sensation of move- 
ment in Impression, Sunrise — and some of 
Louis Leroy's disdain for the painting — 
stemmed in part from Monet's use of 
quick dabs of paint, which required the 
viewer's eye to blend the colors. "Wall- 
paper in its original state is more finished 
than this seascape!" Leroy groused. 

And yet it is clear that some of the 
color combinations the Impressionists 
used have so little luminance contrast 
that they create the illusion of motion. 
We perceive illusory motion in images 
made from equiluminant colors for the 
same reason w'e don't see appropriate 
depth in these images: our Where sys- 
tem can't distinguish between equilumi- 
nant colors. Therefore if an image is 
composed of equiluminant colors, our 
What system can see those objects, but 
our Where system — which is responsi- 
ble for our ability to see motion and 
position, as well as depth — cannot reg- 
ister their position and stability, so they 
can seem to jitter. 

Monet's The Poppy Field Outside ojArgcn- 
teuil is a good example of this illusion. The 
red of the flowers is nearly equiluminant 
with the green of the grass and the skirt 
of the woman in the foreground. Our 
color-selective What system can easily 
distinguish the poppies and the skirt 
trom the grass. But the colors, although 
bright, do not have enough luminance 
contrast for our Where system to see 
them. Their position seems uncertain, 
giving them an illusory instabihty. They 
can seem to move, as if stirred by a breeze. 

Our eyes can be similarly tricked by 
repetitive high- contrast lines, which tend 


LEVELING THE FIELD: In Monet's The Poppy 
Field Outside of Argenteuil, the red flow- 
ers, green grass, and purple skirt ore 
approximately equiluminant. Because our 
"Where" system cannot see them clearly, 
their position seems uncertain. They can 
seem to move, as if stirred by a breeze. 

to create motion perpendicular to their 
own orientation. Light shining through 
horizontal Venetian blinds, for example, 
will induce the appearance of vertical 
motion on an adjacent wall, a phenome- 
non known as the McKay illusion. 

An extreme example of this illusion 
is Isia Leviant's Enigma. The juxtaposition 
of luminance -contrast borders with areas 
of equiluminance can cause the illusion of 
motion; after looking at Enigma for a 
minute or so, the \iewer should notice a 
streaming effect in the colored circles. 
The streaming always mo^•es perpendicu- 
larly to the high- contrast lines, which 
induce it. We do not yet understand 
why a large field of high- contrast lines 
induces an illusion of motion. Some of 
N'lonet's paintings likely induce a rrdld 
form of this deception to help create 
their illusory sense of movement. 

Art Mystery 

Five hundred years after Mona Lisa sat for 
Leonardo da \mci, we're still trying to 
understand what makes her painted 
image so Mehke. She seems to srmle until 
you look at her mouth, then her snule 
fades, like a dim star that disappears as 
soon as you gaze directly at it. One popu- 
lar idea is that Leonardo used sfumato — a 

technique of subtly blurring sharp out- 
Imes — to make her expression ambigu- 
ous. That hypothesis would mean that her 
smile would \'ary depending on the view- 
er's imagination or state of mind, but its 
variabilit}' is more systematic than that. 

While looking at the painting one day, 
I noticed that Mona Lisa's expression 
changed according to how far the center 
of my gaze strayed from her mouth. These 
systematic transformations suggested 
that her lifelike quaUty was not so myste- 
rious after all. Her smile, I realized, is dif- 
ferentially apparent in different parts of 
our \isual field. 

To understand how Mona Lisa's smile 
would look at a range of eccentricities, I 
processed images of her face to reveal its 
fine, medium, and coarse components. A 
clear smile is more apparent in the coarse 
and medium components of the images 
than in the fine detail image. This means 
that if the center of your gaze falls on 
the background or on Mona Lisa's hands, 
her mouth — which is then seen by 
your peripheral, low-resolution \ision — 
appears cheerful. When you look direct- 
ly at her mouth, your high-resolution 
foveal \ision sees details that take away 
the grin. This explains the elusive quaUty 
of her expression: you literally can't catch 
her smile by looking at her mouth. 

The spatial imprecision of our periph- 
eral vision has interesting imphcations 
for our perception of some Impressionist 
paintings, too. In Monet's Rue Montorgucil 
in Paris, Ecstival of]une50, 1878, for example, 
details are spatially jumbled. If you look 
carefully at the flags just to the left or 

right of the center of Rue Montorgucil you 
can see that the blue, white, and red 
brushstrokes, representing the stripes 
of the tricolored flags of France, are not 
always well aligned or even adjacent 
to one another. This spatial imprecision 
differs from a simple blurring: it mimics 
the spatial imprecision in our peripheral 
visual field. 

Our peripheral vision occasionally 
makes erroneous correlations between 
objects seen and objects known to exist. 
This phenomenon, called iUusory con- 
junction, occurs when items are present- 
ed either peripherally or transiently. The 
flags along the Rue Montorgucil look 
fine when you first glance at the paint- 
ing, but not if you look directly at them, 
or after you study those parts specifical- 
ly. The painting's spatial imprecision is 

SPINNING WHEEL: In Isia Leviant's Enigma, 
the juxtaposition of luminance-contrast 
borders v/ith areas of equiluminance can 
cause the illusion of motion; after gazing 
at the painting for even a moment, the 
viev/er should notice a streaming effect 
in the colored circles. 




Wen then, thev often find it imDOSsible to duolicate tho' 

LOOSE LIPS: Mona Lisa's expression 
changes depending on how for the 
vie>ver's center of gaze is from her 
mouth. A clear smile is more evident 
on her face in details that show the 
coarse and medium image components 
(left and center) than in the one that 
shows only fine details (right). 

not immediately noticeable because our 
owTi spatial imprecision allows iUusory 
conjunctions to complete the objects. 
That explains why we see complete flags, 
even though many of them are just single 
strokes of paint. 

Low spatial precision can lend vitali- 
ty to a painting, because our visual sys- 
tem fills in the picture differently with 
each glance. It also gives the painting a 
transient feel because such imprecision 

is compatible with a single glance, a 
fleeting moment in time. Because of the 
low spatial resolution of peripheral 
vision, we cannot take in a detailed 
percept of the entire scene in a single 
glance; we see clearly only the part of 
the scene that our center of gaze hap- 
pens to light on. "The visual sensation 
that imprints itself on the retina lasts but 
a second, or e\'en less," wrote Impres- 
sionist painter Gustave Caillebotte, a 
master of the art of capturing a fleeting 
moment. "That's the impression that we 
had to pursue." 

By comparison, Nicolas Poussin's 
highly detailed, action-packed Rape of 
the Sabine Women looks relatively static, 
because we can see hundreds of details. 
Seeing so many details is incompatible 
with the transience of the incident 
depicted — by the time our eyes move 
from one act of savagery to another, the 
scene should have changed. The longer 
you look, the colder and more frozen 
the figures in the painting seem. 

In the Shade 

When a Ught source illuminates a three- 
dimensional object, different parts of 
the object's surface reflect different 
amounts of light, depending on the 
angle of the light hitting them. We see 
these differences as changes in lumi- 
nance, or shading, which is another 
depth cue that, like perspective, artists 
must learn to render. 

To use shading effectively, artists ha\'e 
to surmount several challenges. They 
must learn to see luminance gradation 
and to evaluate luminance independent 
of color. Even then, they often find it 
impossible to duphcate those luminance 
ranges with pigments because of the lim- 
ited range of reflectances available even 
with the best paints. The range of lumi- 
nances in a given scene is almost always 
far greater than the array of values an 

artist can achieve using pigments. Inside 
a typical room, for example, luminances 
vary widely: a light source, such as a 
window or lamp, might be hundreds 
of times brighter than the shadowed 
region under a desk. The luminance in 
outdoor scenes usually varies by a factor 
of a thousand. 

We know that luminance contrast, 
not color, is necessary for depth percep- 
tion. A corollary of this principle is that, 
as long as you have the appropriate lumi- 
nance contrast, you can use any hue 
you want and still portray a shape in 
three dimensions with shading. In Henri 
Matisse's La Femme au Chapcau. for exam- 
ple, the shadows and most of the planes 
of the subject's face are pecuhar colors. 
Although it is difficult to imagine what 
kind of lighting would cast blue and 
mauve shadows, the three-dimensional 
shape of the woman's face does not seem 


uminance inaepenaem o 
uminance ranses with Disments. 

unnatural because the patches of bizarre 
colors have the correct relative lumi 
nance to represent planes and shadows. 
Matisse himself explained, "While foh 
lowing the impression produced on me 
by a face, I have tried not to stray from 
the anatomical structure." 

Matisse had discovered that he could 
use any hue and still portray the three 
dimensional shape he wanted as long 
as the luminance was appropriate. The 
art collector Leo Stein, who eventually 
bought the painting, wrote, "It was a 
tremendous effort on his part, a thing 
brilliant and powerful, but the nastiest 
smear of paint I had ever seen." 

A Double Take 

Although late Renaissance painters 
attained a photographically realistic use 
of perspective and shading, those tech 

niques alone could not con- 
vey an authentic feeling 
of three-dimensionahty. No 
matter how convincingly 
an artist renders shading 
and perspective, two other 
important cues — stereopsis 
and relative motion — inform 
the viewer's brain that the 
painting is, in fact, flat. 

Since our two eyes view 
the world from slightly dif- 
ferent positions, the images 
on the two retinas differ 
slightly. Stereopsis is the 
ability of our visual system 
to interpret the disparity 
between the two images 
as depth. A stereoscope, a 
device popular in the mid- 
nineteenth century, pre- 
sented two sUghtly differ- 
ent pictures, one to each 
eye, to give a vivid sense of 
depth. The View-Masters 
many of us enjoyed as chil- 
dren also work on this principle, show- 
ing three-dimensional images of ptero- 
dactyls, volcanoes, and Donald Duck. 

The same part of the brain that codes 
stereopsis codes depth from relative 
motion, so movements as small as the 
distance between our eyes are large 
enough to produce a strong depth sig- 
nal. We glean information about dis- 
tance from the relative motion of 
objects as we move past them. When 
you walk down a street at night, for 
example, the objects close to you, such 
as the trees along the sidewalk, seem 
to pass more quickly than the houses 
or trees farther away. Those at even 

FREEZE FRAME: Nicolas Poussin's The 
Rape of the Sabine Women depicts a 
great cJeal of action, yet it seems more 
static than Monet's Rue Montorgueil 
because our visual system cannot 
register so many details at once. 

UNFLAGGING ENERGY: The spatial imprecision 
in Monet's Rue Montorgueil in Paris, Festival of 
June 30, 1878, generates vitality because it is 
consistent with a single glance, a moment in time. 

greater distances, such as the moon, 
seem stationary. 

We also pick up relative movement 
cues from the small head motions we 
make even when we stand still in front 
of a painting. No matter how skillfully 
the artist conveys depth through the use 
of perspective and shading, because the 
images in our two eyes are identical and 
because there is no relative movement 
between objects in the painting, our 
brains register the painting as flat. 

The Impressionists found multiple 
ways to trick our brains, though. In most 
Impressionist paintings, cues such as 
perspective or shading, rendered in lumi- 
nance contrast, convey a sense of depth. 
The blurriness and deliberate lack of 
details characteristic of many Impres- 
sionist paintings also contribute to a 
sense of three-dimensionality. To see 
stereoscopic depth, the image needs to 


HAT TRICK: Despite its odd colors, the shape 
of the v/oman's face in Matisse's La Femme 
au Chapeau seems natural because the 
relative luminance of the pigments is 
appropriate, even if the hues are not. 

be detailed enough to allow us to detect 
the slight differences between our two 
eyes' images. By eliminating some spatial 
details and blurring others, an artist can 
hinder stereopsis from revealing the flat 
ness of the image. This allows other 
depth cues in the painting, such as shad 
ing and perspective, to produce a more 
powerful signal because they are not as 
strongly contradicted by stereopsis. 

The notable ability of some Impres- 
sionist and Post Impressionist paintings 
to invoke an illusion of depth, or a sensa- 
tion of atmosphere, also likely arises 
from the rendering of semiregular pat- 
terns of lea\'es or flowers, or e\'en from 
coarse brush strokes. Rue Montorgucil, for 
example, produces an illusion of depth 
because of the semirepetitive patterns 
of the flags. Ironically, this effect goes 
beyond what realism could achieve — 
short of making two slightly different 

paintings and using stereo \'iewers — to 
generate a sense of depth. 

The sense of atmosphere is particular- 
ly striking in Pierre -Auguste Renoir's A 
Girl Gathering Flowers. The dabs of paint 
can be mismatched in the images in our 
two eyes, giving the painting an illusory 
sense of a three-dimensional volume 
filled with smaU floating elements, such 
as flower petals, insects, and pollen. 

Vision Quest 

The ways in which we process color and 
luminance hold ramifications for more 
than paintings; they also affect our per- 
ceptions of tele\ision, computer graph- 
ics, photography, color printing, and 
movies. These technologies are all flat, 
like painting, so they use the same kinds 
of cues — perspective, shading, and 
occlusion — to give an illusory sense of 

The higher levels of the "Where" system are located 
above the ears, in the parietal lobe, and the higher levels 
of the "What" system are located in front of the ears, in 
the temporal lobe. Because these areas are distinct, peo- 
ple can experience damage — from stroke or injury — to one system 
v/ithout the other being at all affected. 

When the Where system is damaged, people hove trouble locat- 
ing objects; they have difficulty perceiving motion and depth, distin- 
guishing right from left, and seeing complex objects in their entirety. 
Much of our knov/ledge of the function of the Where system comes 
from neurological studies of people v/ho have sustained damage to 
the parietal lobe, such as Zasetsky, a Russian soldier who suffered 
a bullet wound to his left parietal area during World War II. 

After his injury, Zasetsky described his vision as being severely 
disorganized and spatially fractured, though his recognition of indi- 
vidual objects was unimpaired. He had trouble grasping objects that 
he could plainly see because they would turn out to be to one side 
or the other of where he perceived them to be. He could not tell right 
from left, and he could see only one small part of an object or a 
scene at a time. His world would "glimmer fitfully and become dis- 
placed, making everything appear as if it were in a state of flux." 
The neurologist Josef Zihl has described a stroke victim whose 
world, unlike Zasetsky 's frenetic universe, appeared strangely static. 
Bilateral damage to her parietal lobe had affected her motion per- 

ception. She found herself in danger crossing streets because she 
could not judge the speed of approaching cars. "When I'm looking 
at the car first, it seems far away," she reported. "But then, when I 
want to cross the road, suddenly the car is very near." She eventual 
ly learned to gauge the distance of approaching vehicles by their 
sound. For this patient, even pouring a cup of tea was tricky, 
because she could not perceive the rising level of the tea in the cup. 
Midair, the stream of fluid appeared frozen, like a glacier. 

When people suffer damage to the What system, they have trou- 
ble recognizing objects, animals, people, or colors. These visual loss- 
es can be surprisingly specific, indicating a high degree of functional 
specialization. With some kinds of stroke, for example, people can 
lose the ability to recognize colors but not the ability to recognize 
objects, or vice versa — evidence that the What system is further sub- 
divided into a color system and a form system. 

The process of object recognition must also be further subdivided, 
because strokes can occasionally result in uncannily specific losses of 
object recognition abilities. Some patients may retain a capacity to 
recognize living things only, for example, or lose their ability to iden- 
tify fruits and vegetables. Not uncommonly, small lesions in the tem- 
poral lobe can result in a selective loss of the ability to recognize 
faces but not any other kind of object. 

Neurologist Oliver Sacks has written about an artist whose injury 
had caused him to lose only his color perception; his other visual 




depth. They also ha\'e the same problem 
as paintings in that our stereopsis regis 
ters the images as flat. 

But movies and television ha\'e the 
potential for a powerful additional 
depth cue — relative motion. If you close 
one eye and gaze steadily at, say, the 
edge of this magazine, you may find that 
it does not seem clearly in front of back 
ground objects. But by moving your 
head slightly from side to side you can 
make it jump back into proper apparent 
depth. That is because relative motion 
of objects at different distances is a 
strong cue to their distance from the 
observer. Relative motion of objects in 
movies and television can be a powerful 
cue to depth and can even induce an 
illusion of being propelled through 
space. Who didn't have to grip their seat 
the first time they saw the opening 
credits for Star Wars^ 

Recent ad\'ances in our understanding 
of the human visual system allow us to 
look at art — and our perceptions of the 
world — in new ways. Without under- 
standing the underlying neurobiology of 
color and luminance recognition, artists, 
ad\'ertisers, psychologists, and the tech- 
nology industry have discovered various 
phenomena that turn out to be based on 
the parallel organization of our visual 
systems. It will be interesting to see 
whether an explicit understanding of 
the neurobiology of vision will lead to 
more sophisticated effects and illusions 
and a greater knowledge of brain func- 
tion in general. ■ 

Margaret Livingstone, PhD. is a professor of 
neurobiology at Harvard Medical School. This 
article was largely adapted from her booh 
Vision and Art: The Biology of Seeing, 
published by Henry hi. Abrams. Inc. in 2002. 

paint in Renoir's A Girl Gathering Flowers 
can be mismatched between our two 
eyes, leading to a po>verful sensation of 
a three-dimensional volume filled v/ith 
small floating objects. 

abilities remained intact. The artist was still able to recognize and 
render objects, but his entire world — even the world he saw while 
thinking and dreaming — became gray and drab. He was profoundly 
disturbed by the wrongness of the appearance of everything around 
him. People resembled "animated gray statues," and he found their 
gray flesh so abhorrent he began to shun them. Food looked so dis- 
gusting that he had to close his eyes to eat. Finally, he began to con- 
sume only achromatic foods, such as black olives and white rice. 

Some people with temporal lobe lesions that interfere with the 
What system can accurately copy drawings of objects without 

having the slightest idea what those objects are. Others with a 
lesion in a slightly different part of the temporal lobe cannot rec- 
ognize faces that had once been familiar, such as those of family 
members, friends, or celebrities. One man who had suffered a 
stroke told his doctor, "I can see the eyes, nose, and mouth quite 
clearly, but they just don't add up." At his social club one day 
the stroke victim noticed that a stranger kept staring at him; 
when he finally asked the steward who the ill-mannered bloke 
was, he learned that he had spent the afternoon gazing at him- 
self in a mirror. ■ 

of a vision test, Oliver Sacks 
asked two of his patients to 
try to reproduce the image in 
the left panel. The center panel 
shows a reproduction made by a 
red/green colorblind person; the 
right panel shows a reproduction 
made by a man vt^ith a lesion in 
the color processing part of his 
brain. The perception and draw- 
ing ability of the man vt^ith the 
lesion were intact, but his color 
perception was completely gone. 
He was much more profoundly 
colorblind than the red/green 
colorblind patient. 










A neurologist reflects on the compulsions 
and frustrations of literary creativity 


gave premature birth to twin boys. One baby did not survive 
the comphcated dehvery and the other died soon after, clutch- 
ing his mother wdth a hand so tiny it barely encircled her finger. 
For ten days, Flaherty grieved. But then suddenly, she says, "The 
sun and the moon swdtched positions." For the next four months, 



en my attention wandered during medical schc 
hen my classmates would get mad because th< 

in a rare postpartum mania, Flaherty 
experienced her first episode of hyper- 
graphia — the medical term for an over- 
powering desire to write. She wrote 
everywhere, all the time; on her left arm 
as she gripped the steering wheel of her 
car, on squares of toilet paper in public 
bathrooms, on Post- it notes in the mid- 
dle of the night. 

As a neurologist at Massachusetts 
General Hospital, Flaherty was able to 
diagnose herself — and to put her symp- 
toms to good use. Within a year she had 
completed her first book. The Massachu- 
setts General Hospital Handbook of 'Neurology, 
which has since been translated into 
three languages. And now in a forth- 
coming book. The Midnight Disease: The 
Drive to Write, Writer's Block, and the Creative 
Brain (Houghton Mifflin, 2004), Flaherty 
explores both hypergraphia and its seem- 
ing antithesis, writer's block. The Bulletin 
recently asked her about her personal and 
professional \iews on literary creativity. 

Bulletin: How did your first bout with hyper- 
graphia begins 

Flaherty; One morning, exactly ten 
days after my babies died, I woke up 
feeling as if a switch had been thrown 
and a thousand volts were flowing 
through me. It was like in Hamlet, when 
"the sheeted dead / Did squeak and gib- 
ber in the Roman streets." I was fifled with 
an overwhelming compulsion to write. 
That's all I was conscious of — I had impor- 
tant ideas that I needed to write down 
because otherwise I would forget them. 

Everyone kept saying, "It's a grief reac- 
tion," or "She's depressed." But I liked my 
sorrow. I was wallowing in it — I think that 
would be the appropriate clinical term. 
Depressed people don't enjoy being 
depressed; I vaguely remembered that 
from medical school. I was full of grief, 
but I was euphoric too, and I had no 
intention of getting better, even though 

there were days that I felt that my brain 
was going to explode, or that I was like a 
balloon attached to the earth by a single 
frayed thread. 

So I wrote all the time. In the middle 
of the night, I'd write on a PalmPilot or on 
tiny Post- it notes. I would stick the Post- 
its on the wall, collect them the next 
morning, then type my scribbles into the 
computer. My husband, Andy, who was 
incredibly supportive through all this, 
told me, "That's when I knew you were 
sick. The smallest Post-its — ^why not even 
the medium-sized ones?" I don't know 
why — it just had to be the tiny ones. 

About some of my behavior, I'd think, 
well, doesn't everybody do that? Many 
people write on their hands; I just 
extended that up my arm while driving 
across the Longfellow Bridge. And every- 
one will .suddenly jot something down — 
but maybe not on toilet paper in the 
public bathroom, and not for half an hour. 

Bulletin; Anddidntyou write on napkins in the 
cafeteria at Mass GeneraU 

Flaherty; Lots of people write on nap- 
kins — that's normal! Physicists do it all 
the time. Go to MIT. They're all in the 
cafeterias writing on napkins. Except 
when they attend fancy dinners — then 
they write on the damask tablecloths. 

Bulletin; What were you scribbling on all those 
Post-its and napkins^ 

Flaherty; It was largely autobiographical. 
Some of it was just phrases, ideas that I 
can't decipher now but at the time led me 
on all sorts of tangents. It was a mentally 
ill flight of ideas, and yet those scribbles 
were where most of the ideas for my book 
on writing came from. As it is, the book is 
largely memoir disguised as neurology. 

But if I were hypergraphic all the time, 
I could never be a \\'riter. First of all, I'd 
die of exhaustion. And the writing would 

be much too personal and disorganized, 
its associations too loose. Editing is best 
done when you're normal or a whiff 
depressed, willing to toss out the trash. 

Then, after four months of mad scrib- 
bling, another switch was thrown, and 
I became completely torpid, with no 
impulse to write — or e\'en to mo\'e. It was 
peaceful, unless I tried to write or speak. 
Then I felt as though my lungs were full of 
water. That lasted about six weeks. 

The following year, by a strange sym- 
metry, I gave birth to premature — but 
healthy — twin girls, my wonderful 
daughters Katerina and Elizabeth. Again, 
I experienced four months of hyper- 
graphia followed by a short period 
of semi-catatonia. 

Whatever brain-hormonal interac- 
tions caused hypergraphia in me might 
have caused more tradirional postpartum 
psychosis in someone with a different 
premorbid personality. The truth is that, 
even before the pregnancies, I'd always 
been inclined to write a bit more than 
normal. When my attention wandered 
during medical school lectures, for exam- 
ple, I would furiously write whatever 
thoughts came into my head. Then my 
classmates would get mad because they 
assumed I had taken great notes that I 
just wasn't willing to share. And this past 
summer I tried hard not to start a new 
book — the result was an oratorio libretto 
about Jacob wrestling with the angel, a 
165-page biographical sketch, and a chil- 
dren's book on the adventures of a picky 
eater and the Loch Ness monster. 

In general, h)'pergraphia doesn't guar- 
antee great writing, just lots of it. H)'per- 
graphics tend to be internally dri\'en; they 
write for their own pleasure or to deal 
with their own demons. Being paid a 
dollar a word can make you prolific, but 
it's not the same as being hypergraphic. 
Sometimes hypergraphia can take the 
form of copying the same poem over and 
over. I've done that, because of the black- 



'ectures, I would furiously write whatever thoughts came into 
^sumed I had taken great notes that I wasn't willir'* ""^ -^"-^ 

ness of the letters on the page and the way 
the \-o\\els rang Uke bells in my head. Or 
hv'pergraphics make useless Usts of every- 
thing, like lists of their favorite songs. And 
to a more pathological extreme — I can't 
think of a tactful word — 

Bulletin: Like jack ^licholson m The Shining? 

Flaherty: Yes, typing reams of "All work 
and no play makes Jack a dull boy." 

Bulletin: Which famous authors have been 

Flaherty: Isaac Asimo\-, who wrote near 
ly 500 books, is a classic example. He 
would sit down and compose 90 words 
a minute on his typewriter and report- 
edly never suffered a blocked moment. 
Everyone thinks of Proust as hyper- 
graphic because he wrote such a long 
novel over such an extended time. Other 
writers often described as hypergraphic 
include Stephen King, Charles Dickens, 
Honore de Balrac, Agatha Christie, 
Anthony TroUopc, John Updike, Herman 
Melville, and Joyce Carol Oates. 

Bulletin: You mention in your hook that Joyce 
Carol Oates objects to people calling her writ- 
ing compulsiye. 

Flaherty: Yes, and I can understand that, 
since most people consider "compulsi\'e" 
an insult. But doctors get blase about 
using medical terms. We medicalize 
ever)l:hing. When conferences get dull, 
we entertain ourselves by diagnosing each 
other — congenital toe walking, swan 
neck deformit)', frontal release signs. 

People don't realize that not all aspects 
of mental illnesses are terrible, although 
most mental illnesses, of course, cause 
great suffering. Some of my patients ha\'e 
told me that, for them, a single episode 
of depression was far worse than living 
through World War II or cancer. But an 

. m^^^^^^ WORTh 

>• ^1 


* Alice Flaherty, who has 

* experienced firsthand 
the hypergraphia she 
now treats in patients, 
considers the phenome- 
non both a disease and 
a blessing. 

obsessive- compulsive personality can be 
useful if you're an engineer checking the 
Challmger for flaws. That's going to be my 
next book: Make YourManal Illness Work for 
You. If you have narcissistic personality 
disorder, become a dictator. 

I think one reason Joyce Carol Oates 
gets irritated about being called compul- 
sive is that she deri\'es pleasure from her 
writing. That's important to remember. 
Some people write because they're 
unhappy, but when they're writing, 
they're often filled with joy. 

People who didn't know me when I 
was hypergraphic ask why I call it a 
disease, especially since I also consider 
it a blessing. I call it a disease, in part, 
because of the way my writing sucked me 
away from e\'erything else. And because 

of how strange it felt to be suddenly 
propelled into a creative state by what 
were probably postpartum biochemical 
changes. I hated to think that writing — 
one of the most refined, even transcen- 
dent talents — should be so influenced by 
biology. On the other hand, as a neurosci- 
entist, I realized that if we can get a han- 
dle on fluctuations in creativity, we might 
be able to find ways to enhance it. 

Bulletin: U'/iar causes hypergraphia^ 

Flaherty: Certain brain conditions can 
trigger it, and they all seem to involve 
the temporal lobes. It was Norman 
Geschwind ['51] and colleagues who first 
showed an association between temporal 
lobe and hypergraphia. Fyodor 



I of my patients was referred to me because a c 
etbook and on her clothes. She even wrote ten-p< 

Dostoevsky's temporal lobe epilepsy 
almost certainly caused his prolific writ- 
ing. Just before his seizures, he would 
enter a state of rehgious ecstasy in which 
his world was flooded with meaning. 
Between seizures, he wrote hypergraph- 
ically, often about his struggle with the 
fact that the periods in which he seemed 
to experience the highest truths were 
also the product of a disease. 

Like Dostoevsky, some people with 
temporal lobe epilepsy display a group 
of personahty traits — coUectix'ely called 
the Geschwind syTidrome — that include 
hypergraphia, strong religious or philo- 
sophical interests, and wild mood swings. 
But about 50 years before Geschwind did 
his work, the German psychiatrist Emil 
Kraepelin described hypergraphia in 
people with bipolar depression. 

Although at first glance temporal lobe 
epilepsy and bipolar disorder seem quite 
different — one a neurological disease 
with seizures, the other a psychiatric dis- 

order with mood swings — on closer 
examination, the symptoms and the 
treatment overlap a great deal. Clinicians 
often have trouble deciding whether to 
diagnose temporal lobe epilepsy or bipo- 
lar depression in patients today, so imag- 
ine how difficult it is to identify the afflic- 
tions of people long dead. Biographers 
have diagnosed Edgar Allan Poe and Lord 
Byron both ways as they have tried to 
account for Poe's and Byron's prolific 
writing and mercurial temperaments. 

Schizophrenia also can cause hyper- 
graphia. With his copious manifestos and 
journals, Theodore Kacyznski, the Una- 
bomber, is a classic example of a high- 
functioning schizophrenic who became 
hypergraphic. Drugs sometimes induce 
hypergraphia as well. One of my patients 
was referred to me because a neuroleptic 
her doctor had prescribed suddenly made 
her start WTiting in her pocketbook and 
on her clothes. She even WTOte ten-page 
letters to her parents while sitting in the 

same room with them. And Robert Louis 
Stevenson churned out aU 60,000 words 
of The Strange Case of Dr. jekyll and Mr Hyde 
during a six-day cocaine high. 

Bulletin: Don't a high proportion of \mters 
have bipolar disorder^ 

Flaherty; Yes, or depression with bipolar 
features. The work of psychologist Kay 
Redfield Jamison and others has shown 
that wTiters are ten times more likely to 
be bipolar than the rest of the popula- 
tion, and poets are a remarkable forty 
times more likely. 

Bipolar disorder is strongly genetic. 
You can see this in writing families like 
the Jameses, in which the mildly affected 
members are more productive than both 
their relatives with a more se\'ere form 
of the disease and the general population. 
Henry James had unipolar depression and 
his famous siblings William [Class of 
1869] and .AUce were mildly bipolar, but 
their brother Robert's writing career was 
crippled by his severe bipolar disorder. 

Danielle Steel, whose late son also had 
se\'ere bipolar disease, hkely has enough 
of the bipolar gene cluster to make her 
hypergraphic — she's published more 
than 60 books — but not enough to be 
impaired. Severe mental illness lea\'es ht- 
tle room for creari\ity. Syhia Plath, who 
was bipolar, once said, "When I was lQ, 
that's all I was." 

Bulletin: In your book, you state, "Hyper- 
graphia is neither painful (except sometimes to 
the reader) nor common. \\ 'riter's block is both." 

Flaherty: Yes — all blocked writers share 
two traits: they don't write despite being 
intellectually capable of doing so, and 
they suffer because they're not writing. 
One of my favorite descriptions of block 
was by a nineteenth-century English 
poet, John Clare: "They have cut off my 
head, and picked out aU the letters of the 



her parents while sitting in the sam^jogj^^b 


alphabet — all the vowels and conso- 
nants — and brought them out through 
my ears; and then they want me to \\'rite 
poetry! I can't do it." 

The list of famous writers with block 
is long — Franz Kafka, Virginia Woolf, 
Saul Bellow, William St\Ton, Syhia Plath, 
Norman Mailer, Ralph Elhson, Katharine 
Mansfield. Gustave Flaubert, who had 
temporal lobe epilepsy and wrote hyper- 
graphically, crossed out nearly as many 
words as he wrote. Of course, these writ- 
ers managed to be productive enough to 
become famous. One of the tragedies of 
block is that it also afflicts unknown 
people — talented individuals who just 
disappear from their fields because they 
stop being able to produce. That's why 
treating block as a disease isn't fri\olous. 

Bulletin: h writer's block the true opposite 
of hxper^raphki' 

Flaherty: No. Originally I thought it was, 
but you can suffer from both almost 
simultaneously, whether they alternate 
at different times of year — as in people 
with seasonal patterns of productivi- 
ty — or whether you're blocked in one 
genre but not in another. Samuel Taylor 
Coleridge is a classic example of this: he 
used to churn out metaphysical treatises 
at the same time that he was paralyzed 
in his attempts to write poetry, which is 
what really mattered to him. 

So, from that phenomenological point 
of view, hypergraphia and block seem 
too closely related to be considered true 
opposites, just as mania and depression 
are difficult to present as complete oppo- 
sites. E\'eryone from Freud on has argued 
that mania is, in many ways, closer to 
depression than it is to the normal emo- 
tional state. And that's true on a number 
of axes, including treatment. Treating the 
mania often treats the depression. 

There seems to be a frontal temporal 
lobe interaction that is important for 

Lucky Stars 

Some authors are blessed with 

a proMic — e\en compulsive — 

capacity for writing 

Danielle Steel 

Stephen King 

Marcel Proust 

Isaac Asimov 
Honore de Bolzac 
Joyce Carol Oates 

Henry James 
Edgar Allan Poe 

writing — and probably other creative 
endeavors — and if this interaction 
becomes imbalanced, problems arise. In 
people with injuries to the temporal lobe, 
you see disinhibitions and loquacious 
speech, as opposed to the laconic kind 
of speech typical of frontal lobe injuries. 
Wernicke's aphasia, where you talk gib- 
berish, and Broca's aphasia, where you 
struggle to speak, are the classic exam- 
ples. And there is evidence, although pre 
liminary, that when your frontal judg- 
ment mechanism gets out of control, 
you can end up \\'ith creative block. 

The frontal temporal lobe axis turns 
the received \iew of creativity 90 degrees, 
because until recently, the only theories 
about the creatix'e brain were ones that 
speculated that the right hemisphere is 
the seat of creativity and the left hemi- 

sphere just helps you do your taxes. I'm 
oversimplifying, but the picture is still 
much more complicated than even the 
best of those theories suggest — not only 
because of the way the temporal lobes 
on both sides may drive creative work, 
but also because of the role the frontal 
lobe may play in judging or editing the 
often over-exuberant products of tem 
poral lobe changes. 

Bulletin: How can writiiiij disorders be treated? 

Flaherty: For many hypergraphics, the 
question should be, do they want to 
be treated? And what exactly is it that 
you're treating? Is it bad hypergraphia, in 
that they write poorly? Or are you treat 
ing hypergraphia in which the quality 
of writing is relatively good, but they're 
so obsessed with writing that they're 
alienating family and friends? 

For hypergraphics v\-ho want help, 
redirecting some of their energy to the 
editing phase can help. And mood stabi- 
lizers are both anticonvulsants and anti- 
manics, so they get at the two most com 
mon neurological causes of hypergraphia, 
temporal lobe epilepsy and mania. 

As for block, WTiters have a long histo 
ry of self-medicating, usually unsuc- 
cessfully, with everything from alcohol 
to coffee to amphetamines. These days, 
people who complain to a psychiatrist 
of writer's block tend to be treated for 
depression or anxiety. 

Also, some blocked writers struggle 
with critical inner voices. The writer 
.Anne Lamott personified one of these 
critics as, "the vinegar-lipped Reader 
Lady, who says primly, 'Well that's not 
very interesting, is it?'" Low doses of 
atypical dopamine antagonists may 
quieten those inner x'oices. 

Bulletin: You mention in xourbook that different 
parts of the brain control the drive to write and 
the abilitx to write. Can you elaborate on that? 


fetors who write have a rich experience to mine, 
c papers and case workups in a prose style that k 

Flaherty: Roughly, the limbic system 
primarily controls emotion and drive and 
the cerebral cortex is more concerned 
with cognition. Yet the neurology of 
emotion and cognition are tightly inter- 
twined. The cortical area that is the most 
cormected to the limbic system is proba- 
bly the temporal lobe. And the reason the 
temporal lobe can trigger hypergraphia 
is probably because the limbic system 
produces our strong biologic drive to 
communicate, which in turn drives the 
speech area of the temporal lobe. 

In psychological terms, it seems that 
drive is more important than talent in 
producing creative work. The psycholo- 
gist Dean Simonton has argued, for exam- 
ple, that the composers who produced the 
greatest music were simply the ones who 
wrote the most. Mozart and Beethoven 
composed all the time, whether walking 
down a street or attending a dinner party. 

Bulletin: What can writing disorders teach us 
about creativity^ 

Flaherty: Temporal lobe changes can 
increase creative drive in fields besides 
writing; for instance, one kind of tempo- 
ral lobe dementia causes people to begin 
painting or composing even though other 
aspects of their lives are degenerating. 
Vincent van Gogh — who almost certain- 
ly had temporal lobe epilepsy — painted 
with an amazing fury, sometimes produc- 
ing a fresh canvas every 36 hours. At the 
same time, he wrote several long letters 
a day to his brother, Theo. Robert Schu- 
marm, who had bipolar disorder, wrote 
feverishly at the same time that he was 
composing music feverishly. 

The rate of mental illness is about 70 
percent for musical performers, poets, 
prose WTiters, painters, and composers, 
but only 25 percent for doctors, scientists, 
politicians, and businesspeople. Does that 
mean that doctors' creativity stems from 
a different source? Or that they are less 


creative? I'd guess it's that doctors have 
more social pressure to hide psychiatric 
illness. After all, physicians have higher- 
than-average suicide rates. 

Clearly, though, you don't have to be 
sick to be creative. It may be that engag- 

Les Miserables 

Many famous authors have 

wrestled with the torments 

of writer's block 

Franz Kafka 

Virginia Woolf 

Saul Bellow 
William Styron 

Sylvia Plafh ^"™~° 

Ralph Ellison 
Mary McCarthy 
Norman Mailer 

ing in creative work not only is a sign of 
health, but also makes you healthy. The 
relationship between illness and cre- 
ativity doesn't mean we should foster 
disease. Perhaps we should think of cre- 
ativity as an adaptive response to diffi- 
cult situations such as illness. Many 
plants won't bother to flower unless 
they're stressed just a little; people are 
like cyclamen. 

Focusing on the relationship between 
Ulness and creati\ity is also useful because 
mental illnesses are often exaggerations of 

normal brain states that allow us to see 
more clearly how a mechanism works, 
even in healthy people. It would be tragic 
to go from there to pathologizing creati\i- 
ty, though. It makes more sense to go in 
the opposite direction and notice that 
everyone shares traits with the mental- 
ly ill. Unfortunately, doctors are trained to 
see all facets of illness as bad, and we tend 
to dismiss patients who complain of "soft" 
medication side effects, such as decreased 
creativity, as simply being noncompHant. 

Bulletin: Why arc so many doctors also writcrsl 

Flaherty: Just the other night, I was sit- 
ting next to a department chairman at a 
stuffy dinner party. He was asking ques- 
tions about my book, and I began to 
suspect that his interest was more than 
casual. So I asked him pointblank, "You 
write, don't you?" "How did you know?" 
he rephed, sounding defensive. I pursued 
it: "What are you working on?" He 
hemmed and hawed, and I finally inter- 
rupted, "You're writing a thriller, aren't 
you?" Of course he was — they all write 
thrillers. I could name you ten Harvard 
doctors who are writing thrillers. At 
least the young ones are; when they get 
older, they write memoirs. 

Doctors who write have a rich expe- 
rience to mine because they're constant- 
ly confronted with issues of life-and- 
death importance. It's that limbic tug — 
the ache and blood of medicine. 

The flip side of that, though, is that 
doctors are trained to write scientific 
papers and case workups in a prose style 
that is not only bad writing, but also often 
actively neurotoxic to creativity. I'd bet if 
you did volumetric MRIs of residents 
exposed to the typical progress note, 
with its passive voice and its refusal to 
describe the patient as a human being 
rather than as a collection of prostheses 
and malfunctioning organs, you'd find 
that after four years the language areas 

only bad writing, J^^^so often neurotoxic to creativity. 

of the residents' brains had shriveled up 
to the size of walnuts. Just a suspicion. 

Bulletin; You seem to he focusing your own 
research more and n\ore on issues of creativity. 
What arc you working on now? 

Flaherty: I'm interested in biological 
interventions that affect creativity. For 
instance, my colleague Shelley Carson 
and I are studying the effect of hghtboxes 
on undergraduates, because even people 
without seasonal affecti\'e disorder seem 
to experience winter dips in producti\'ity 
that could benefit from phototherapy. 

As for drugs, I'm primarily interested 
in those that affect dopamine. Many 
creative people with mood disorders 
hesitate to take dopamine antago- 
nists — the neuroleptics — because they 
feel that the drugs flatten their creativi- 
ty. If we could show that the newer neu- 
roleptics don't dampen creativity, com 
pliance might improve. That would be 
incredibly beneficial, especially for peo- 
ple at high risk for suicide. 

Another study will focus on stimu 
lants like Dexedrine, because a fair num 
ber of studies suggest that stimulants can 
actually boost creativity. But they need 
to be used only intermittently and in 
low doses — sometimes a difficult propo 
sition, given their addictive potential. 

Much of my research has been on the 
basal gangha's role in initiating mo\'e 
ment, and I have been intrigued with their 
role in sparking ideas as well. Some 
patients who have deep brain stimulators 
for movement disorders Like Parkinson's 
disease experience profound changes in 
mood and idea generation. 

One of my patients, who has Tourette's 
s)Tidrome, is a remarkable example of 
this. Although her tics have nearly dis- 
abled her — she has broken her limbs and 
bhnded one eye, she works successfully 
as a medical editor, is happily married, 
and is so bright and persuasive that two 

of my colleagues at Mass General — Emad 
Eskandar and Rees Cosgrove — agreed to 
her request for experimental surgery to 
preser\'e her remaining \'ision. The stimu 
lator has helped calm her tics — I no 
longer hear her chirps and cusses dowTi 
the haU. To our surprise, though, it also 
controls her moods and her creativity. 

When her stimulator releases current 
deep under her frontal cortex, she gets 
mildly depressed and has little interest 
in getting out of bed, likely because the 
stimulator has inhibited her nucleus 
accumbens, a dopamine-rich region of 
the brain involved in drive. But when we 
stimulate less deep in the brain, which 
probably activates her nucleus accum 
bens, she stops sleeping and begins 
sending me long emails with all kinds of 
grand schemes — biotech companies, 
new government agencies. Because she's 
so smart, though, they're not just crazy 
ideas, but good crazy ideas. Our next 
step will be to test her on various ere 

ativity parameters with the stimulator 
turned off, then back on. 

Less invasive technologies, such as 
transcranial magnetic stimulation, may 
offer some of the same effect temporarily. 
One case report even described a subject 
in whom TMS had induced the sensation 
of being visited by the Muse. 

It may seem ludicrous to imagine sit 
ting under a contraption resembling an 
old-fashioned hair dryer to stimulate your 
creativity, like something out a 1950s sci-fi 
fhck. But It's not just a question of ridding 
vvTiters of their block because of pubhsh 
or-perish pressures. There are worldwide 
problems urgently in need of creative 
solutions. Just imagine if you were trying 
to develop a vaccine for a lethal new virus 
and a wand waved over your temporal 
lobe could help you. To the extent that 
insights into the writing process may 
carry over into broader problem solving 
realms, they have the potenti.J to benefit 
many people in profound ways. ■ 




A patient turns to poetry to try to preserve 
the memories he is fast losing to disease 

by Rafael Campo 

me in English as I welcomed 
him into my exam room that 
late spring day, which was odd 
because we'd always conducted 
our discussions in Spanish at 
his semiannual visits. 1 noticed 
his English was halting and too formal, like the way my grandparents had 
spoken it; 1 assumed he had learned his second language relatively later in life, as 
they had. This linguistic rigidity would soon prove portentous. ■ Eduardo was 
76 years old and, except for mild hypertension and diabetes, was remarkably 
well preserved. He wore his thick black hair combed back with a strong- 





ardo began to create poems that seemed to 

poem about what h^jkej^xj^y 


smelling pomade, and in his suit jacket's 
pocket a handkerchief folded as precise- 
ly as an origami figure declared his fas- 
tidiousness. He told me that he had once 
been a promising young writer in his 
native Ecuador, but unmentionable cir- 
cumstances had forced him to leave the 
country. When he arrived in America he 
could only find work as a bellhop at an 
upscale hotel. He had stayed in that job 
for 40 years; it had been backbreaking 
work, leaving precious little time, he 
always said, for cultivating one's mind. 
Now that he had finally retired, he 
vowed that would change. 

"Eduardo," I said to him in Spanish, 
"it's Dr. Campo, remember? We can talk 
in castcUano." I expected the flash of his 
smile, the perfect white teeth that I had 
learned were actually dentures when, to 
my surprise, he had popped them out 
into his cupped palm in a smooth, sin- 
gle-handed motion the day I first exam- 
ined him; instead he stared at me vague- 
ly, as though I were speaking in tongues. 

I didn't make anything then of the 
faint tremor in his right arm. In anoth- 
er moment or two, he became his usual 
loquacious self again, telling me all about 
his beloved granddaughter's recent 
piano recital. Out of his wallet came the 
latest picture of her, her pigtails tied 
in pink ribbons, her smile as brilliant 
as his, the flash of the camera reflected 
in one side of the shiny black piano 
against which she stood. He then 
segued to his grand plans to tour Spain, 
where he would visit the haunts of 
Federico Garcia Lorca, Salvador Dali, 
and other members of the avant-garde 
who had been the heroes of his youth. 
After a check of his blood pressure and 
a few marks on a lab requisition, I sent 
him on his way. 

In the ensuing few months, I diag- 
nosed Eduardo with Parkinson's disease, 
which progressed so rapidly that he 
never made his trip to Spain. He fell in his 
apartment while preparing his supper a 
few weeks later; he was unable to take 
the pot off the stove, and the burning 
arroz con polio was what may have saved 
his life, by setting off the fire alarms in 
the building. The paramedics found him 
prostrate beneath the table in his 
kitchen, his left hip broken, his neck 
bleeding, gashed where the knife he'd 
been using happened to strike him as he 
crumpled to the floor. As they wheeled 
him out on a stretcher, he must have 
asked them to bring along his writing 
materials; perhaps he had been in the 
middle of composing a poem, taking a 
fateful break to slice some tomato for his 
salad while the rice simmered. 

He had pen in hand when I strode in 
to see him in the hospital the morning 
after the accident. Now I recognized that 
the blank stare was not so much disori- 
entation as one of the subtler signs of 
Parkinson's disease, which robs those it 
afflicts of most facial expression. A fat 
wad of gauze was taped to his neck. "Do 
you like my new friend?" he asked, refer 
ring to it with a downward motion of his 
chin. "It's like a second head, only it has 
no brain." With that, he mustered a broad 
smile, displaying his fine false teeth. But 
it soon \'anished again. 

When he left the hospital for rehab, 
after a taxing two weeks of surgery 
complicated by post-op pneumonia, he 
presented me with a small packet of 
poems. They were difficult for me to 
decipher, line after line of tiny, shaky 
cursive in Spanish. Because the ink was 
blotched and uneven, I guessed he had 
used a fountain pen to write them. It 

was the first time he had ever shared his 
work with me, prompted, surely, by his 
sudden clash with infirmity. 

He asked me what I thought of his 
poetry when he returned to see me in 
the clinic. I was not especially inclined 
toward literary critique that day; he'd 
weathered a prolonged rehabilitation 
that had been hampered by a further 
steep dechne in his neurological condi- 
tion, and we had much new information 
to re\iew. By now, almost four months 
later, his gait had become a slow shuffle; 
his head CT showed the possibilit)' of 
multiple small basal ganglia infarcts that 
the neurologist thought might explain 
his dramatic deterioration. His forgetful 
ness had also worsened, to the point 
where when I asked about his grand- 
daughter, whether she had played any 
new pieces for him, he couldn't remem- 
ber that he even had a granddaughter. 

Yet the poems, those he could remem- 
ber. In fact, he told me he had set himself 
the task of memorizing them, to combat 
what he called "the stealing of my per- 
sonhood." I wasn't sure whether he 
meant the disease itself, or the sedatives 
that were used to calm his agitation in 
the evenings — a common phenomenon 
called "sundowning" in medicalese (and 
a good if rare example of a medical term 
for something awful that tries to make it 
sound somev\'hat poetic). 

I sat dumbfounded as he went on to 
recite about a hundred lines of his verse, 
the tears coming to his eyes as he 
described, in one particularly moving 
section, his granddaughter at the piano, 
the same talented little girl whom he 
hadn't been able to recall earlier during 
our visit. His words rose and fell with 
all the musicality of a Beethoven or 
Bach concerto, as if her inerasable pres- 



cnce in his mind had found a last remain 
ing outlet. I wondered whether he had 
indeed once published his work, in the 
homeland he could no longer name, in a 
world that he was fast losing. 

Eduardo began to create poems that 
seemed to be attempts to graft himself 
back onto the life he had once known. He 
showed them to me when he came to his 
appointments, now accompanied by his 
new attendant, a jovial, buxom, copper 
haired Haitian woman named ■•\ntoinette. 
He wrote a poem about what he liked to 
buy at the supermarket; another record- 
ed the names of the streets in his neigh- 
borhood; still another, the names and 
relationships to him of various family 
members. There was even a love poem 
for Antoinette, which made her blush 
when he read it aloud, though I was 
quite sure she didn't understand Span- 
ish. I was struck by how the language 
of his poems flowed so effortlessly, no 
matter how mundane their subjects, 
animating his face again with the emo 
tions he otherwise could no longer man- 
ifest. I noticed how they recollected 
information, much of it practically use- 
ful, some of it simply pleasing, that his 
faulty neurons could no longer store. 

A few more months passed; another 
springtime in Boston arri\ed, the golden 
daffodils like trumpeters heralding a 
dainty queen's imminent visit. Eduardo 
failed to keep his morning appointment 
one day; the inevitable phone call came 
the same afternoon, from Antoinette. 
"Don Eduardo, he die," she reported tear 
fully. She said she had found him utterly 
motionless in his bed when she'd come to 
bring him for his appointment; she had 
recognized immediately that the stiffness 
in his limbs when she tried to rouse him 
was very different from that caused by 

Parkinson's disease — "No medicine help 
him now," is how she put it. I thanked her 
for taking such good care of him. .After a 
moment of silence, she told me that she 
had found something he had left in his 
apartment for me and that she would 
bring it to the chnic the next day. 

What she brought was a beautifully 
handmade book of his poems. Pasted on 
the cardboard cover was an old photo- 
graph of a handsome man with thick 
black hair combed back neatly. His 
expression was either very serious or a 
little scared. He sat at a small desk, upon 
which were assembled some sheets of 
paper, a stack of books, and a fountain 
pen with its inkwell; he had cocked his 
head, as though his concentration had 
just been interrupted. The desk was posi- 

tioned before a window, through which I 
thought I could make out a view of dis- 
tant mountains, and at their feet, a rim 
of beach and black water. "Pocsia" was 
inscribed in a familiar, tremulous hand 
beneath the photograph. 

Later that week, at his funeral, 1 sat in 
a pew alone at the back of the church. 
.After the service, I gave the book to a 
little girl in pigtails, who smiled at me 
so genuinely I felt as though I'd known 
her all her life. ■ 

Rafael Campo '92 practices medicine at Beth 
Israel Deaconess Medical Center This essay 
was reprinted from his most recent hook, The 
Healing Art: A Doctor's Black Bag of 
Poetry, '" Rafael Campo, with permission of 
the publisher, W. W. Norton. 



In unraveling the puzzle of how music affects the human brain, neurologistj 




Mark Tude Tramo 


debut on the "Ed Sullivan Show," seven-year-old Mark Jude 
Tramo found himself captivated. By then, his own preco- 
cious musical abihties had caught the eye of a talent scout. 
At the 1964-65 World's Fair, Tramo played classic rock 'n' 
roll on electric guitar for the crowds. By nine, he was per- 
forming as a folk guitarist at Catholic churches. In high 
school he was writing songs. And he produced his first 
musical show — a rock musical — at seventeen. 

While earning his undergraduate and medical degrees, 
Tramo played in a rock group whose demo landed him 
and his bandmates a coveted audition at RCA Records. But 
RCAs offer arrived the same week that Tramo matched 

lay help broaden music's healing potential by Beverly Ballaro 


in neurology at his (irst choice hospital. 
"Given the vagaries of making it in the 
music industry," says Tramo, "the choice 
was clear, but heart-wrenching." 

The recording industry's loss became 
the medical profession's gain. When 
Tramo saw that a new science, dedicated 
to understanding music perception and 
cognition, was on the horizon, he seized 
an opportunity to combine two passions. 
During his residency, it occurred to him 
that the new digital technologies he was 
using to record music could facilitate 
neuroscientific studies of musical timbre 
recognition. And he realized that research 
into how humans perceive music could 
potentially contribute to new therapies 
in the realms of deafness, stroke rehabili^ 
ration, and palliative care. 

To unlock the puzzle of how the brain 
processes tonal information, Tramo began 
working with stroke and split brain 
patients. By analyzing which music- 
processing functions these people were 
unable to perform, he helped determine 

w hich regions of the brain are in\'olved 
in certain music related activities. Those 
studies inspired Tramo, with colleagues 
in the Harvard Program in Neuroscience, 
to develop an experimental model for the 
neural coding of pitch and harmony in 
the auditory cortex of primates. 

The clinical applications that may one 
day out of such understanding are 
the driving force behind Harvard's Insti- 
tute for Music and Brain Science, which 
Tramo co-founded in 2002. The institute 
is dedicated to advancing knowledge 
about the neurobiological foundations of 
music and fighting diseases that impair 
the capacity to perceive, learn, and per- 
form music. Its research also focuses on 
using music to treat children and adults 
with neurological and other diseases. 

Music therapy, says Tramo, may benefit 
patients in every phase of life, beginning 
v^dth premature infants. "Babies in neona- 
tal ICUs are isolated in incubators," he 
says. "They carit see well and are subject- 
ed to an acoustically stressful emiron- 

ment because of all the monitor alarms 
going off." Some studies suggest, he adds, 
that music can help premature infants 
gain weight fa.ster, avoid cardiopulmonary 
distress, and lea\'c the ICU sooner. 

"The degree of neonatal music sensiti\' 
ity is amazing," says Tramo. "Babies can 
percei\'e sounds in the \\'omb beginning at 
about the midpoint between conception 
and birth. By four months of age, they will 
respond to dissonant chords in music 
by squirming and turning away from 
the source." Research, he adds, indicates 
that mu.sical preferences are determined 
in part by environmental exposure. "It's 
analogous to the way humans are born 
with a capacity for speech," he explains. 
"Children quickly learn the 'language' of 
music for their particular culture." 

Yet infants also display preferences 
for certain musical features that cut 
across cultural boundaries. Whether 
based on seven notes, as in most West- 
ern music, or five notes, as in some East- 
ern traditions, Tramo adds, the music of 


all cultures relies on an octave structure 
that can be broken down into a limited 
subset of pitches that are consistent 
from one octave to the next. Babies ha\e 
the auditory capacity to recognize 
octa\-e similarity. 

Infants are not the only potential 
beneficiaries of scientific insight into 
the way the brain responds to music, 
says Tramo. Tonal information processing 
studies may one day lead to apphcations 
in speech therapy and the treatment of 
dyslexia in older children. Adults, too, 
may benefit from mood induction thera- 
py — the use of music to deal with chron- 
ic pain or to reduce the discomfort, anx- 
iety, and depression that often accompa 
ny diseases such as cancer. 

Some studies have suggested that 
exposure to music can modify the 
widely fluctuating blood pressure that 
many coronary bypass patients experi- 
ence postoperatively. Other studies 
indicate that music can help calm 
aggressive behavior, a common problem 

with Alzheimer's patients. And under 
standing how the ear and the brain 
process music can lead to the develop- 
ment of better hearing prostheses, 
cochlear implants, and other bionic 
devices that may alleviate deafness. 

Although music therapy is already 
being used to help patients, Tramo 
acknowledges that "many of the data 
still fall into the realm of the anecdotal." 
The lack of rigorous, controlled cUnical 
studies has prevented music therapy 
from achie\ing the status of a treatment 
whose value is officially recognized 
within the medical profession and cov 
ered by insurance companies. 

Tramo beUeves that the effects are 
there for the measuring. "We already 
understand much about how different 
parts of the brain 'talk' to each other," he 
says. "We know, for exiimple, that the rela- 
tionship between sounds and emotions 
has an anatomical basis. The ner\'e cells in 
the auditory cortex connect to the ner\e 
cells in the medial temporal cortex, which 

controls memory and emotions. Those 
ner\'e cells, in turn, connect to other parts 
of the brain that regulate heart rate, blood 
pressure, and immune response. So, a 
broad connectivity is at work." 

Amid his quest to bring clarity to these 
kinds of scientific issues, Tramo has not 
completely forsaken his artistic voca- 
tion — some of his recordings are getting 
airplay on a 1970s rock radio show, and 
a record label has expressed interest in 
re-releasing an album he recorded years 
ago. He is now working on a digital re- 
mastering of the material. 

But Tramo is devoting most of his ener- 
gy over the next few years to developing 
The Institute for Music and Brain Science, 
stud)ing music perception in stroke and 
epilepsy patients, and, with colleagues, 
"cracking the neural code for pitch and 
harmony" in the primate auditory cortex. 
And he is writing a book about music, 
medicine, and neuroscience. "At this 
point," he laughs, "I think it's safe to say 
that my rock 'n' roll days are o\'er." ■ 

Anne Blooc. 


music's extraordinary power to shape our spirits and sentiments: 
"Music hath charms to soothe a savage breast, to soften rocks, or bend a 
knotted oak." More than two centuries later, Lewis Thomas 37 offered 
a perspective more cerebral than visceral but one nonetheless enamored 
of music's mysterious effects. "Music is the effort we make to explain to 
ourselves how our brains work," Thomas wrote. "We listen to Bach 
transfixed because this is hstening to a human mind." 

The emotional impact of music has come to fascinate a new gener- 
ation of researchers like Anne Blood, instructor in neurology at HMS, 

chords by squirming and turning away from the source." 



who lound hcrscll intrigued by this puz^ 
zle while a graduate student living in 
Los Angeles, the heart of the recording 
industry. So, while a postdoctoral fellow 
at McGill University, Blood decided 
to subject art to the scrutiny of modern 
scientific tools. With colleagues, she 
designed and conducted brain imaging 
studies aimed at illuminating the ori 
gins of music's power to sway listeners' 
moods, both positively and negatively. 

To assess which areas of the brain 
come into play when listeners experience 
an unpleasant emotional response to 
music. Blood exposed a group of test sub- 
jects to a series of recordings that steadi 
ly increased the degree of dissonance. But 
the first order of business was to ensure 
that the subjects would, indeed, find the 
clashing sounds sufficiently unpleasant. 

To this end. Blood chose non- musi- 
cians as test subjects. She also took care 
to exclude from the study aficionados of 
jazz, which characteristically relies on a 
complex interplay of harmonic tension 
and resolution. 

"It's quite common ior trained musi 
cians to develop a taste for dissonance," 
Blood explains. "The pleasure that many 
people derive from dissonance is not so 
much the jarring contrast between two 
particular notes, but the resolution of 
that tension into consonance as well as 
the pleasurable, suspcn.seful anticipation 
of that resolution. In the music we used in 
our study, the dissonance never resolved." 

Music historians, in fact, have demon 
strated how both the Western definition 
and perception of harmony have evolved 
over time. For medieval musicians, 
harmony consisted of simple two- note 
combinations. During the Renaissance, 
three-note chords emerged, and the 
Romantic Era saw the expansion of 
chords into four-part harmonies. Mod- 
ern composers further expanded the 
meaning of harmony; contemporary 
listeners now enjoy dissonant chords 
whose instability would have struck 
earlier audiences as unbearable. When 
Blood finally previewed the most disso- 
nant test tape for a colleague, she was 

gratified by her colleague's assurance 
that it was so awful, "it nearly made her 

feel sick to her stomach." 

When Blood correlated brain activity 
with a dissonance level that increased 
continuously, she made a discovery that 
contrasted with prexious findings. Listen- 
ing to dissonant sounds did not change 
acti\ity in the parts of the brain that t)'pi- 
cally light up in response to other sensory 
stimuli such as visual cues. Instead, as 
the music increased in unpleasantness, 
an area on the right side of the brain indi- 
cated by other studies to be important 
to memory and anxiety — the parahip- 
pocampal gyrus — became active. 

Blood had more striking findings in 
store when she recruited a fresh set of 
test subjects for a study designed to 
examine the impact of positi\'e emotion- 
al responses to music. This time, she 
chose ten trained musicians, knowing 
that the likelihood of e\'oking a powerful 
emotional response to music would be 
higher for someone with a lifelong pas- 
sion for the art. Specifically, Blood wanted 

Gottfried Schlau' 


confirming the astonishing human capacity for neuroplasticity means 
dispelling the notion that the brains of all musically talented people 
come preprogrammed -with an aptitude for music. "I've been happy to 
discover that, for the most part, musicianship and the chance to excel at 
playing a musical instrument are not predetermined by heredity," says 
Schlaug. 'To think that musical potential is already Hmited at birth 
would be quite depressing for all of us who believe in the enormous 
potential of the brain to grow and mature based on experiences." 

Yet, Schlaug cautions, it would be a mistake to discount completely 
the role of genes in the expression of certain musical abilities, such as 


to analyze \\'hat goes on in the brains 
of listeners while they are experiencing 
a powertul emotional reaction indicated 
by the physiological sensation of getting 
shivers down the spine. 

"The tricky part, of course," says Blood, 
"is that, while people from \'arious back 
grounds and cultures report a euphoric 
response to music that uniformly in\-ol\-cs 
sensations of tingling and chills, the 
music that c\'okes such a response differs 
from indi\idual to indi\'idual." To solve 
this problem. Blood asked each musician 
in the study to select his or her own piece 
of music. Her only stipulation was that 
the piece had to be purely instrumental, 
since the brain will inc\'itably respond 
to human voices or vocal cues. Her sub- 
jects' choices ranged from the mournful 
strains of a Barber string piece to the lush 
orchestration of a Rachmaninoff concer- 
to, although Blood points out that other 
types of music outside the classical genre 
can also evoke the same response. 

An analysis of the results revealed a 
pattern of brain response quite distinct 

from what Blood and her colleagues had 
observed in their study of unpleasant 
emotional responses to dissonance. The 
experience of hstening to pleasant music, 
she discovered, did not e\'oke responses 
in the parahippocampal gyrus. 

Instead, during their positive, spine 
tingling experience of feeling mo\'ed. 
Blood's musician subjects all exhibited 
increased activities in areas such as the 
\'cntral striatum, amygdala, and dorsal 
midbrain areas — regions of the brain 
associated with motivation and reward. 
"This was quite striking," Blood says, 
"because these subcortical parts of the 
brain are connected with more basic, 
instinctive impulses and cravings that 
all animals exhibit. They are mostly 
reserved for survival- oriented tasks such 
as eating and reproduction. These are the 
same neural pathways that typically 
show a lot of activity in the presence of 
sexual arousal, for example, or addictive 
drugs. And yet, clearly, music is not nee 
essary for physical survival or the pcrpct 
uation of the species." 

Researchers are still debating why 
Barber's ethereal Adagio for Strings 
should light up the same region of the 
brain turned on by earthier drives 
for food or sex. "Humans are highly 
evolved," says Blood, "but evolution has 
left us with a number of primitive emo- 
tional systems. It may be that the more 
evolved parts of our brains somehow 
patch into the evolutionarily older 
parts and link to them abstract, higher- 
level cognitive processes, such as listen- 
ing to music." 

It may take years before scientists 
arrive, if they ever do, at a definitive 
answer to the question of why humans 
have developed such a strong neurobio- 
logical basis for the appreciation of 
music. "Fortunately, the implications of 
this capacity are not nearly as mysteri- 
ous," says Blood. "If music can stimulate 
areas of the brain linked to such 
intensely positive emotions, this lends 
scientific weight to the popular intu- 
ition that music may offer significant 
mental and physical health benefits." ■ 


absolute pitch. Some lamilies have an 
increased incidence of this ability — as 
do 35 percent of Japanese musicians and 
a roughly similar proportion ol Asian 
American musicians (compared with 
only 10 to 18 percent of their Caucasian 
counterparts). Researchers, he says, arc 
still trying to differentiate the impact 
of early music exposure from potential 
genetic effects. Age at commencement 
of musical training is one strong factor 
in the expression of the absolute pitch 
phenotype, says Schlaug, adding that 
other factors may include a particular 
brain anatomy that is commonly found 
in musicians with perfect pitch. 

But, Schlaug notes, cultural factors may 
be at work as well. Some researchers sus- 
pect that the tonal nature of some Asian 
languages may lend some of their speakers 
a more nuanced perception of pitch. Oth- 
ers have pointed to the rigorous early 
musical education programs that are more 
common in some Asian countries than in 
Western nations. "In addition," Schlaug 

says, "these programs tend to rely on 
teaching philosophies, such as the Suzuki 
method, that strongly emphasize learning 
music through listening rather than 
through reading notation." 

.Although the extent to which genes 
underlie absolute pitch remains a mystery, 
one conclusion of Schlaug's research is 
unambiguous: the experience of playing 
music alters the human brain in profound 
ways. "The idea that experiences can 
shape the brain in ways that we can actu- 
ally measure is relatively new," he says. 

This realization came about when 
Schlaug compared adult musicians with 
non-musicians. He was seeking any 
behavioral differences between the two 
groups, as well as functional and struc- 
tural brain dissimilarities. He identified 
not only a number of characteristic differ- 
ences in the motor and sensory regions 
of the musicians' brains, but also pro- 
nounced changes in the brain regions 
responsible for translating \i.sual-. spatial 
information into motor commands. 

In particular, areas in the superior 
parietal region and in the lateral inferior 
temporal region showed significant 
differences between the two groups. 
Differences were also seen in the cere- 
bellum, where auditory and motor func- 
tions become integrated. The musicians' 
brains, Schlaug discovered, were bigger 
in certain, well- delineated brain regions 
than their non-musical counterparts' 
brains. Moreo\'er, the degree of differ- 
ence in the musicians' brains correlated 
with the intensity and duration of their 
musical training. 

To understand when and how these 
changes take place, Schlaug and col- 
leagues are conducting a longitudinal 
study of more than 75 children between 
the ages of five and seven. The children in 
the experimental group are taking piano 
or string instrument lessons; the control 
group's only exposure to music comes as 
part of their ordinary school curriculum. 
The researchers plan to follow the chil- 
dren for at least three years, taking annu- 


al brain images and subjecting them Co 
\-arious beha\1oral and cogmti\-e tests. 

Although he has completed only the 
first year of the study, Schlaug is already 
seeing, in brain images of the child musi 
cians, differences in the same regions that 
music transforms in their adult counter 
parts. He and his colleagues are also 
tracking any possible transfer effects that 
instrumental training might have on the 
children's oxerall IQs, reasoning abiUties, 
and verbal, visual -spatial, math, motor, 
and auditory skills. 

At first glance, it might seem counter- 
intuiti\'e that a child's ability to bow the 
violin might also enhance parts of the 
brain connected to Nisual-spatial skills. 
But Schlaug points out that these two 
realms may be more related than they 
first appear. 

"To play the violin requires the abiht\' 
to read musical notes," he says, "and then 
the player's brain has to translate that 
visual spatial and time information into 
specific motor commands. Similar opera 

tions might be taking place when some 
one is assembling a jigsaw puzzle. So, it's 
easy to see how parts of the brain that are 
involved in music processing might .ilso 
become better at other tasks that require 
a similar processing." Brain-based sharing 
also takes place between music and Ian 
guage processing tasks, he adds, so that 
instrumental practice, singing, and rhyth 
mic games may strengthen verbal skills. 

"We're learning," says Schlaug, "that 
the human brain is remarkably plastic and 
highly responsive to early experiences." 
At the same time, it is also possible, he 
notes, that "certain learned behaviors 
rather than music-specific factors may 
account for the improved performances 
of musician children in a variety of 
realms. In general, musicians learn how- 
to be attentive and disciplined. Their 
musical training may produce improve 
ments in other areas not so much 
because of specific brain changes but 
because it makes them particularly 
adept at learning how to learn." 

Applying this new knowledge to 
therapeutic opportunities is Schlaug's 
ultimate goal. "The next step," he says, 
"is to think about how we can use music 
to alter the brains of people whose dis- 
eases might respond to such changes." 
To this end, one of Schlaug's postdoctoral 
fellows, Katie Overy, is testing whether 
the phonological skills of dyslexic chil 
dren may respond positively to certain 
musical components. 

Schlaug is also overseeing a study 
focused on melodic intervention thera- 
py — a way of helping stroke patients 
with aphasia to regain, through music, 
the abihty to speak. Although singing and 
speaking do share some brain pathways, 
Schlaug says, they are sufficiently sepa- 
rate so that these patients can stiU sing 
even though they can't talk. "We know 
the intervention works," Schlaug says, 
"the question now is to figure out how it 
works and to see where such understand 
ing can help us develop new ways to 
improve the lives of even more people." ■ 

Roy Hamilton 


curious about the interplay of genetics and experience in shaping the 
human brain. For Roy Hamilton '01, the discovery that blind musicians 
exhibit absolute pitch at startlingly higher rates than their sighted 
counterparts came about by two accidents, one cruel and one happy. 

The first accident took place some 50 years ago when a number of 
premature infants received excessive doses of oxygen in their incuba- 
tors. This exposure caused a displacement of the tissue in their eyes, 
resulting in the condition known as retrolental fibroplasias, which 
rendered them totally, permanently blind. 

alter the brains of people whose diseases might respond. 




A number of vvell-kno>vn 
blind musicians have 
perfect pitch, including 
Ray Charles (pictured 
here), Stevie Wonder, 
and Jose Feliciano. 


The second twist of fate occurred whife 
Hamilton, now a neurology resident at 
the University of Pennsylvania, and col- 
leagues were doing research with 46 of 
these blind subjects in the Beth Israel 
Deaconess Medical Center laboratories 
of HMS faculty members Gottfried 
Schlaug and Alvaro Pascual-Leone. 
Hamilton was focusing on the role of 
cortical plasticity in producing the 
superior tactile acuity that many blind 
people display. Yet in the course of 
interviewing his subjects, he stumbled 
across claims of perfect pitch by a 
remarkable number of them. And when 
Hamilton put his subjects to the test, 
the results bore out the accuracy of 
their self-assessments. 

Against All Odds 

What made the results all the more 
striking, Hamilton says, is that "the phe- 
nomenon of perfect pitch is exceedingly 
rare." Among the sighted general popula- 
tion, absolute pitch occurs on the order 
of less than one in 1,500 people. The rati 
ty of this ability may reflect, says Hamil 
ton, what most studies have indicated: 
that early exposure to musical training 
seems to be a prerequisite for perfect 
pitch in most sighted indi\'iduals. 

If people are not exposed to musical 
training by the age of 11, they almost 
never go on to exhibit perfect pitch. By 
contrast, among musicians who go on 
to receive Western musical conserva- 
tory training, the rate hovers around 
18 percent. 

To no one's surprise, the nine blind 
research subjects who reported no 
musical background did not have 
absolute pitch. But 12 out of the 21 sub- 
jects who had received some musical 
training — an astonishing 57 percent — 
did display this talent. And Hamilton 
was even more intrigued to learn that 
this startling percentage existed even 
though the average age at which mem 
bers of his blind cohort had begun 
musical training was eight years, four 
months — much later than the average 

training onset age of sighted musi- 
cians — and some of his subjects were as 
old as 14 before they first picked up a 
musical instrument. 

"The fact that these blind musicians 
were still able to develop perfect pitch 
at two or three times the rate of preva- 
lence among sighted musicians clearly 
suggests that something unique is going 
on with blind people," Hamilton says. 
"The challenge now is to figure out how 
their brains differ, both functionally 
and morphologically." 

Some Stars Are Born 

The idea that the brains of sighted and 
blind people arc not identically wired is 
not new. It has long been known, for 
example, that sighted people have great 
difficulty in mastering Braille. What 
has not been as clear is how much of the 
distinction is tied to genetic factors and 
how much to experiential factors. 
Absolute pitch, says Hamilton, does 
appear to have a genetic component. 

The chances of perfect pitch existing 
in identical twins, for example, are high- 
er than they are for non-identical twins. 
Studies have also confirmed a signifi 
cantly higher incidence of absolute pitch 
in certain racial and ethnic groups. Asian 
populations, for example, seem to have 
elevated rates of perfect pitch compared 
with non-Asian populations. And, 
what's more, these higher rates appear to 
exist independent of the musical scale or 
environment in which people from those 
populations are trained. 

In the case of the subjects in Hamil- 
ton's study, however, the link between 
blindness and absolute pitch ability had 
to be explained in other than genetic 
terms; all of the subjects in this study 
had been born sighted but became blind 
shortly after birth. 

Amazing Grace 

A clue as to what non- genetic factors 
might explain the amazing rate of 
absolute pitch ability in Hamilton's 

blind subjects came from previous 
brain-imaging studies comparing sight 
ed musicians with non musicians. In 
those studies, researchers had discov 
ered a pattern of anomaly; while some 
degree of asymmetry normally exists 
between the left and right hemispheres 
of the brain in all sighted people — with 
the left side being larger — this asymme- 
try is significantly exaggerated in sight- 
ed people with perfect pitch. 

Yet, in blind musicians graced with 
absolute pitch, Hamilton says, this char- 
acteristic asymmetry doesn't appear as 
pronounced. "This suggests," he explains, 
"that if you are blind due to a peripheral 
cause, such as retrolental fibroplasias, 
and you've managed to develop absolute 
pitch ability, the mechanism by which 
you've done so may differ from that 
employed by the brains of sighted musi- 
cians with absolute pitch." 

The leading theory as to what that 
mechanism might be, Hamilton says, is 
predicated on the idea of compensation. 
Some researchers believe that, in blind 
people, the area of the brain that would 
normally be used for vision gets co- 
opted for non-visual tasks, such as 
music. Functional brain imaging appears 
to bear this theory out, in that tasks 
such as sound localization and pitch 
discrimination seem to increase activi- 
ty levels in the visual cortex. The dra- 
matically enhanced haptic acuity of 
such individuals, Hamilton adds, may 
similarly hinge on a co opting of the 
occipital lobe. 

"It's really not surprising," Hamilton 
says, "that this might be the case. Think 
about it — a whopping 40 percent of the 
cortex in a normal human brain is devot- 
ed to one sense: vision. To lose this 
particular sense delivers a greater blow 
than the loss of any other. The brain's 
remarkable ability to reallocate the siz- 
able assets normally dedicated to sight 
goes a long way toward enriching the 
lives of blind people." ■ 

Beverly BaUaro is associate editor of the 
Harvard Medical Alumni Bulletin. 

of 11, they almost never go on to exhibit perfect pitch. 


by Gerald Colman 


A surgeon returns to Vietnam 
to exorcise war memories — and 
to lift a stigma of birth from a 
new generation of children Jt 

^ n 

.^ w 




the heat of the jungle colhcled with 
the artificially cooled interior of the 
plane's cabin. As the other soldiers 
and I Stepped off the commercial 
jet that had brought me — drafted 
midway through my surgical 
residency — to Vietnam in 1969, the stewardesses 
wished us luck. In the thick jungle air, I could soon 
hear American F-4 Phantom fighter jets screaming 


overhead on their way to and from bomb- 
ing runs in Cambodia. When the pilots 
cut in the afterburners, the planes would 
generate a huge, distincti\-e kaboom. 

I was initially assigned to a sleepy vdl- 
lage along the Mekong Delta. For several 
days, I almost forgot why I was in Vietnam. 
I read War and Peace and spun fantasies of 
spending the coming year catching up on 
all the hterature I hadn't had time to enjoy 
once the rigors of medical school and resi- 
dency had taken o\'er my Ufe. 

Fantasy quickly collided with redity 
when I was summoned to a meeting with 
the CIA officer in charge of assigning 
American physicians to help win over 
the hearts and minds of the Vietnamese. 
"You've got surgical skills," he told me, 
"and they need you bad up in I Corps." 
My heart sank. Even a novice like me, 
who'd been in country for only a few 
days, understood that I'd just pulled the 
worst possible assignment. 


The I Corps area served as a buffer 
zone in central Vietnam between the 
forces of the North and South. U.S. and 
South X'ietnamese military units had 
established bases and outposts all over 
Quang Tri province and along the 
demilitarized zone, where the fiercest 
ground fighting and aerial bombard- 
ments of the war were taking place. No 
one wanted to go there. 

Soon after I received my dreaded 
orders, a clerk came running up to me 
saying, "Hey Doc, there's a helicopter 
heading up to Quang Tri that can give 
you a lift." Two pilots, clad in what 
appeared to be black pajamas, met mc at 
a Huey chopper. They worked for Air 
America, a clandestine air carrier that 
supported the CIA outfit to which I'd 
been assigned. 

On our two hour trip north, the pilots 
flew low to the ground, hugging the dirt 
road that served as the main supply 

artery from the cit)' of Danang to Quang 
Tri province. We passed o\'er villages, 
rice paddies, and graveyards, whose tra- 
ditional round burial mounds were 
unmistakable from the air. 

The helicopter finally touched down 
in the midst of what appeared to be an 
old citadel of some kind. "Doc, we're 
here!" the pilots announced as they 
dropped me off, in the middle of nowhere. 
"Have a good tour!" they yelled cheerfully 
as the)' took off. 

As the whirr of the chopper blades 
faded, I stood there, dumbfounded, in 
the middle of a deserted field, clutching 
a Naugahyde satchel with my tennis 
racket absurdly sticking up out of it. I 
couldn't help but panic: had the pilots 
made a ghastly mistake? My God, had 
they deposited me on the wrong side of 
the DMZ? 

Just as I was ready to jettison all hope, 
a jeep came into \iew. The driver intro- 
duced himself as an American advisor to 
the South Vietnamese army, then imme- 
diately radioed the local hospital, "Hey, 
I'N'e got your new doctor!" Exhausted and 
in a state of shock, I wondered how I 
would ever survive this godforsaken 
place for an entire year. 

Operational Difficulties 

The hospital at Quang Tri was composed 
of ten buildings located inside a walled 
compound. It was within those walls 
that I would quickly find myself, at age 
29, a half-trained surgeon charged with 
caring for a population de\'astated by its 
unlucky proximity to one of the hottest 
military spots on the globe. 

By the time the war ended, the heavi- 
est bombing campaign in history had 


destroyed many of the province's vil- 
lages, and the U.S. military's widespread 
use of the defoliant Agent Orange had 
transformed much of the lush jungle 
landscape into something resembhng a 
lunar surface. But when I arrived, the 
earth was still green and most of the 
province's inhabitants had not yet fled. 
CIA and USAID officials explained that 
I would be responsible for running a 
400-bed hospital designated to serve 
the needs of all the South N'ietnamese 
civilians and military personnel in the 
province. If I failed to help these people, 
they would receive no care at all. 

When I learned that I would be deliv- 
ering all babies and handlmg all surgery 
for related complications, my first 
thought was, "Damn, I haven't done any 
obstetrics since my student rotation at 
the Boston Lying in Hospital." My sec- 
ond thought was that I was going to be 
awfully busy. I would be solely responsi- 
ble for 300,000 people, a large percentage 
of whom were women of childbearing 
age who ga\'e birth nearly e\'ery year. 

While working at the hospital, I li\-cd 
in a compound by the river with two 
other Americans. Surrounded by a high, 
concrete wall, our villa was encircled, 


except for the entrance, by claymore 
mines. Machine-gun-toting Hmong 
guards, imported from neighboring Laos, 
manned outposts on the perimeter. 

Although they had been recruited for 
their fierce anti-Communist sentiments, 
the guards, clad in ragtag shorts and san- 
dals, had an unnerx'ing habit of faUing 
asleep huddled around their teapot; sev- 
eral times a night we would take turns 
making sure they were awake. Not long 
before my arri\'al, the compound had 
been violently ransacked by a gang of 
Vietcong who forced their way in with- 
out firing a single shot; they had seized 
the wife of one of the guards and threat- 
ened to kill her before his eyes. 

While driving from my villa to the 
hospital for middle-of-the-night emer- 
gencies, I was always fearful of the \'iet- 
cong. When a call would come in, I 
would hop into my jeep and navigate 
toward the hospital gates. I always kept a 
loaded M-16 rifle on the seat next to me. 

Wet Behind the Ears 


On my first day on the job, I encountered 
a woman with a difficult obstetrical 
presentation. I knew I had to turn the 

IN THE LINE OF FIRE: Previous spread, China Beach during a trip the author took in 
1993; clockwise from upper left, the author in Vietnam in 1968; the remains of a 
Catholic church that was destroyed v/hen U.S. forces routed Vietcong who had been 
hiding there; a wounded Vietnamese civilian on a hospital ship in the South China Sea; 
the hospital in Quang Tri; and the author standing in front of his operating room in 1970 




baby's head a certain way — I just didn't 
know how. As they exchanged glances, 
I could sense the doubt of the \'iet 
namese nurses assisting me. 

I announced that I urgently needed 
to use the men's room. Leaving the 
patient in stirrups, I retreated to the 
bathroom, surreptitiously grabbing an 
obstetrics textbook en route. There, I 
furiously studied the pictures before 
returning to the OR and successfully 
rotating the baby's head, as if I had 
done it a thousand times. It was my 
first big surgical test in Vietnam, and I 
was hugely relieved to have passed it. 

More challenges followed. Mid^ 
wives routinely handled most deliver- 
ies but they sent especially difficult 
cases to the hospital. Presentation de la 
poule — in which the baby's arm was 
sticking out of the mother's body but 
his head and body faced backward — 
was a common comphcation. So were 
uterine ruptures. On more than one 
occasion, I delivered a baby floating 
free in the mother's abdominal cavity. 
Once I even found a baby nestled 
against her mother's liver. 

It was not unusual for me to care for 
a laboring woman who had been trans 
ported 30 miles to the hospital on a 
blanket strung between bamboo poles 
shouldered by human bearers. One 
such patient was a woman in labor 
who had been struck by a guard's stray 
bullet. The bullet passed through her 
pregnant belly sideways. When we 

delivered the baby by emergency C-sec- 
tion, we found that he had sustained a 
single, small-bore gunshot to his but- 
tock. Mter closing up the mother, I 
sutured the baby's wound. Both mother 
and child made a good recovery. 

As time wore on, I grew bolder and 
more confident, even though my work- 
ing conditions were unimaginable by 
the standards of the Boston surgical 
world. More often than not, flies in the 
primitive and not terribly sterile OR 
would alight on the intestines of 
patients on whom I was operating. 
Somehow, the patients never seemed to 
become infected. 

The hospital at Quang Tri had no EKG 
machine, no cardiac monitors, and no x- 
ray machines except for a rehc from 
World War II. I learned to rely on surgi- 
cal intuition and common sense. And I 
learned to improvise. With few sutures 
available, I found myself using industrial 
silk to close up wounds. If I bent a nee- 
dle, instead of discarding it, I bent it back. 
These habits would later come in handy; 
when a woman on a plane I was traveling 
in unexpectedly went into labor, I dehv- 
ered the baby, then successfully tied off 
the cord using the string from a tea bag 
scavenged from the plane's galley. 

Tragically, not all of my work in \'iet 
nam revolved around bringing mothers 
and babies safely through childbirth. I 
saw many vicious, war- related mutila 
tions. The X'ietcong fiQed landmines with 
pieces of chain, nails, and other lethal junk 




so that when they were detonated, their 
contents might blow 30 holes in the 
intestine of any civilian unfortunate 
enough to step on such a device. I soon 
learned to repair such ravaged intestines 
in four minutes flat. 

But first things always came first — 
after making the initial incision, I often 
discovered that the patient had an abun 
dance of worms drifting in the abdomi- 
nal cavity. 1 would simply scoop the 
worms out b\' the handful and toss them 
into an antique enamel bucket kept at 
my feet for this \-cry purpose. 

Other trauma cases roUed through the 
OR doors when Vietnamese soldiers 
carelessly cleared their weapons by dis- 
charging them into the air. When the bul- 
lets fell back to earth, they sometimes 
injured unlucky cixilians. I once operated 
on a man who'd been lying on his stom- 
ach, asleep in his grass-covered hut, when 
he was struck by a bullet "falling out of 
the sky." The round lodged near his spinal 
column. Although he had arrived crip- 
pled by his injury, the patient was able to 
walk out of the hospital unassisted. 

I also saw a heartbreaking number of 
children. Many of them were burn \ic- 
tims who had sustained horrible injuries 
from cooking fires that would blaze out 
of control because Vietnamese mothers 
had stoked them with military jet fuel. I 
didn't have a skin graft knife or mcsher 
a\'ailable, so I used a straight razor and 
sterilized wooden shingles as backing to 
mesh the grafts. 

Another large percentage of children I 
treated were injured by rifle propelled 
grenades. Attracted by their fluorescent 
turquoise color, small children would 
pick them up and playfully smash them 
on rocks, causing them to detonate. 
Other, savvicr children knew the risks 
but cracked open the grenades anyway. 

SCENES FROM VIETNAM: Clockwise from bottom left, a Vietcong woman 
wounded in battle whom the author treated for skull fractures; the author 
and Le Ba Dung performing surgery on a patient with an intestinal wound; 
the author standing vt^ith an M-16 next to a sandbag bunker; food vendors in 
Hanoi years after the war; Le Bo Dung v/ith two of his children; and the three 
doctors who ran the hospital at Quang Tri (the author stands in the center) 

hoping to make some money by selling 
on the black market the abundance of 
shot found inside. 

While about hall of my non obstetri 
cal cases \\'ere related to war trauma, the 
other half consisted of patients suffering 
from ailments I had pre\iously only read 
about. Amoebic abscesses and rabies 
were two of the once exotic, now rou- 
tine, problems I encountered. I some- 
times found huge tapeworms rurming 
the entire length of the intestine, and 
other conditions that, untreated, had 
simply run out of control; 1 once removed 
a 26-pound dermoid cyst, with teeth and 
hair, from a woman's uterus. 

On the flip side, though, I saw 
almost no obesity in my Vietnamese 
patients. Surgical training on American 
patients raised on rich Western diets 
had accustomed me to expect aortas 
transformed by disease into thick, arte- 
riosclerotic pipes. It was eye-opening 
to me to find, in Vietnamese patient 
after patient, aortas that were thin, pli- 
able arteries beating smoothly with a 
soft whooshing sound. 

Risky Business 

As the end of my tour of duty approached, 
all I wanted to do was make it home in 
one piece. I'd managed to sur\-i\-e for near 
ly a year and was determined to keep a 
low profile. "Short-timer syndrome" — in 
which, with a month to go in his tour, a 
soldier would hunker down and refuse to 
take any risks — was a common phenom 
enon. This trend was reflected in a popu- 

lar cartoon from the era that depicted a 
helmet on the ground with two boots 
sticking out from underneath it. When 
my last month came up, I permitted 
myself to think for the first time, almost 
euphorically, "I'm going to make it!" 

And yet I'd already taken all kinds 
of foolish risks. I'd ventured with col 
leagues to the local beaches for cook 
outs, in spite of the constant danger of 
attack by the Vietcong. With a para- 
chute strapped to my back, I'd flown at 
the controls of a military observation 
plane on one of its missions. In return 
for this privilege, I allowed the pilot to 
observe some of my surgeries in the OR; 
he was later killed when he accidentally 
smashed his plane into the side of a fog- 
shrouded mountain near Danang. 

And on Sundays, I had frequently 
accompanied a young Vietnamese sur- 
geon, Le Ba Dung, to visit attractions 
such as the old imperial tombs. On our 
wa); I relied entirely on his intuition to 
judge if the road was safe. 

Le Ba Dung had been assigned to 
work with me in the OR. When the war 
stopped at midday, as it customarily did 
because of the oppressive heat, he would 
often invite me to join him, his wife — an 
English teacher — and their children for 
lunch in their hut. We worked closely 
together for the entire year of my tour of 
duty. As it turned out, I never had a bet- 
ter friend in my life. 

When it was time for mc to leave 
Vietnam, Le Ba Dung and I promised to 
stay in touch. We corresponded until 
1975, when the Communist North \'iet- 


SAVING FACE: Operation Smile's mission of surgically erasing the stigma of cleft lip 
and palate has transformed the future prospects of these Vietnamese children and 
many others like them. Below, a woman in a Hanoi marketplace the author visited. 

namese took power, rendering commu 
nication impossible. 

Into the Mouth of the Lion 

When the MIA issue came to the fore in 
the 1990s, one of my colleagues in our 
plastic surgery practice mentioned that 
he was a friend of Bill Magee, the plastic 
surgeon who had co founded Operation 
Smile. Magee had identified the need that 
many people in other countries had for 
clctt lip and palate surgery. This type of 
surgery seemed to provide an ideal focus 
because it can result in such dramatic 
improvements; a child goes into the 
operation disfigured and, moments later, 
emerges looking normal. Almost like 
magic, the child's future job and marriage 
prospects brighten considerably. 

I joined Operation Smile on one of its 
earliest trips to Vietnam, in 1991. I fig- 
ured that returning to Vietnam would be 
an opportunity to do good surgical work 
for people who really needed help — and 
I wondered if I might be able to track 
down my old friend, Le Ba Dung. 

Flying back into Hanoi felt like plac- 
ing my head into the mouth of a lion. I 
was returning to an area near where I 
had served my tour of duty, and I was 
afraid that the sight of rusty reminders 
such as old jeeps and military equipment 
would be unbearable. 

But when I arrived, I was surprised to 
discover that most traces of the Ameri- 
can military presence were gone. I later 
found out that, when the American mih- 
tary vehicles became useless thanks to a 
lack of spare parts, the Vietnamese had 


broken them down and sold the metal to 
the Japanese as scrap. The Japanese, in 
turn, had converted this material into 
passenger cars for export to American 
markets — an irony that delighted offi- 
cials in \'ietnam's postwar Communist 
regime, who rejoiced in turning a profit 
at their old enemy's expense. 

Before our arrival. Operation Smile had 
sent personnel to alert the communit)'. 
On our first day, more than a thousand 
people showed up to be screened. We 
knew that we had a finite amount of 
time, so triage was a necessary but 
wrenching part of the program. 

Working from 7:00 a.m. to 10:00 p.m. 
for three solid weeks, we repaired about 
300 cleft lips and palates. Some of the 
patients had gone to great lengths to seize 
the life-transforming opportunity. One 
ten-year-old girl had made the 30-niile 
bus trip alone, because her family couldn't 
afford to join her. .Another patient was a 
man in his fifties. In a tenminute repair 
job done with the use of a local anesthetic, 
I was able to erase the disfigurement 
that had burdened him with a lifetime 
of stigma, shame, and suffering. 

As it had been during wartime, swim- 
ming provided a respite from all the hard 
work. When I announced one day, 
toward the end of the trip, that my col- 
leagues and I were going swimming that 
afternoon, the Vietnamese director 
insisted, "But we have a very important 
meeting you and your team must come 
to!" In the end, all 35 team members 
grudgingly agreed to attend. 

When we entered the meeting hall, 
we were astonished to see all 300 of the 
patients we had operated on, most of 
them still in bandages. At the front of the 
room was a barrel full of daffodils. One 
by one, each patient presented a daffodil 
to the doctor who had operated on him 
or her. You don't often see surgeons cry, 
but there wasn't a drv eve in the room. 


I've since made several other trips 
with Operation Smile, two to X'ietnam, 
three to Russia, one to Thailand, and one 
to the Philippines. On each, I've done 
mostly cleft hp and palate surgery, along 
with treating some burn patients. But I 
haven't done any more trips since the 
September II terrorist attacks increased 
the risks for Americans travehng abroad. 

Chasing Shadows 

On my first Operation Smile trip back to 
Vietnam, I'd asked after my old friend Le 
Ba Dung all over Quang Tri but no one 
would give me a clear answer. When I 
returned to the States from my second 
trip back to Vietnam in 1999 — during 
which I had made another round of fruit- 
less inquiries — I was stunned to find a 
letter from Le Ba Dung sitting on my 
desk. In it, he informed me that he had 
just immigrated to California. He'd 
recently been admitted to the hospital 
for a kidney stone, he explained, and 
while there, he had gotten hold of a 
physician directory and found my name. 

To celebrate our reunion, Le Ba Dung's 
wife faithfully prepared all my favorite 
Vietnamese dishes, which she remem 
bered from 25 years earlier. But conver- 
sation with my old friend was strangely 
limited and awkward. Sensing my con- 
fusion, one of Le Ba Dung's sons, now a 
grown man, pulled me aside to whisper, 
"My father's crazy now; they beat him 
up, you know." 

Le Ba Dung, I learned, had been a POW 
in a communist re-education camp for 

five years. There the former surgeon 
attended ideology lectures in the morn- 
ing and, a leather strap looped around his 
shoulders, pulled a plow through the 
rice paddies in the afternoon. He never 
worked as a surgeon again. 

Le Ba Dung had emerged from the 
camp a broken man. Then, not long 
after he'd been set free, another conflict 
erupted between China and Vietnam, 
and he had been placed in detention for 
yet another year out of fear that he 
might subvert the war effort. 

When the U.S. government estab- 
lished an amnesty program that allowed 
some of its former Vietnamese alUes to 
immigrate to the United States, Le Ba 
Dung, his wife, and their four children to 
were able to relocate in 1999. 

When I last saw Le Ba Dung, he was 
hving in public assistance housing in 
Loma Linda, California. The former sur- 
geon had found a job sewing buttons on 
shirts. .-Vlthough he was not the same man 
whose friendship I had treasured in the 
past, we stayed in sporadic touch until 
2002. But the last time I tried to contact 
him, his phone number had been discon- 
nected, and no one had any forwarding 
information for him or his family. The 
disappearance of my friend remains a 
ghostly reminder of the elusiveness of clo- 
sure for so many touched by the Ameri- 
can experience in Vietnam. ■ 

Gerald Colman '66, an associate professor of 
surgery at Albany Medical College, has been 
practicing plastic surgery in Albany, New York, 
for 28 years. 





An ophthalmologist reveals 
an eye for detail in the wild 

lSIONS of 

photographs by JAMES D. BRANDT 


me a SS-millimeter camera. It was my grandfa- 
ther's beat'up camera from the 1930s, a Kodak 
Retina — some might say an early subliminal 
cue for me to become an ophthalmologist — 
and I was hooked. By the time I turned twelve, 
I had convinced my parents to let me turn one 
of our bathrooms into a darkroom. 

rd been interested in nature photography all 
along, but it became a serious calling during my 
sophomore year in college, when I joined a six- 
month expedition to Antarctica to do field 
research on antifreeze in fish. Although the 
experience fueled my desire to become a marine 
biologist, when I realized that jobs were scarce, 
I decided to go to medical school. 

As a photographer, I'd always been interested 
in vision and optics, so ophthalmology seemed 
a natural choice for me. And now as an oph- 
thalmologist with an eye behind the lens, I find 
myself drawn to the eyes of animals gazing 
back at me. I also find myself seeking patterns 
in nature, whether the nubby green ridges of 
a crocodile's back, the velvety feathers on an 
eagle's breast, or the tangled web of brown 
capillaries in a shark's watchful eye. ■ 

]amcs D. Brandt '82 is director of the glaucoma service at the 
UC Davis Medical Center 


[Simple sea anemones, Cali^rnia's'Monterey Bay] 



[Clownfish, Great Barrier Reef, Australia, and Adelie penguin, Antarctica] 

• ^4 



m" ^ 



[Bald eagle, v^ildlife refuge in Florida, and emerald boa, aquarium in California] 





Trained to preserve lives, a physician grapples 
with the execution of a friend on death row - 


by Andrew G. Dean 


drove past an empty guard shack, down a half-mile of 
road, and past some duck ponds to reach the Diagnostic 
and Classification Prison in Jackson, home of Georgia's 
death row. We passed through two metal detectors and 
four steel-barred doors before walking down a long cor- 
ridor to visit Ron for the last time. ■ Five visitors had 
gathered with Ron in a wire-mesh-enclosed visitors' 
room. One hulking, black- clad tactical squad member 



was posted inside the room and another just outside 
the door. We joked and cried and swapped stories. 
Ron had blown his cash account on photo tickets, 
and we posed with him while another prisoner 
snapped away with a Polaroid. At three o'clock, the 
guards pronounced our visit over. Ron waved and 
smiled as he retreated dowoi the hall, his six-foot-six, 
340-pound frame flanked by a h;tlf dozen guards. 

Ten months earlier, after more than two decades 
on death row, Ron had come within several hours 
of execution, but the Georgia Supreme Court had 
ordered a stay while deliberating whether death by 
electrocution constituted cruel and unusual punish- 
ment. After the court ruled in October 2001 that it 
did, lethal injection replaced the electric chair, and 
four chemical executions had quickly taken place 
in Georgia. Ron's was to be the fifth. 

The State Board of Pardons and Paroles had lis- 
tened, unmoved, to testimony about Ron's history 
of mental illness. One of my HMS classmates. Jay 
Jackman '64, had flown in from California to inter\dew 
Ron and to file an expert declaration outUning Ron's 
mental problems. The Reverend Joseph Lowery, a leg 
endary colleague of the Reverend Martin Luther King, 
Jr., had dehvered an emotional appeal, declaring that 
the time to stop this kind of killing had come. It didn't 
matter that Ron was white, Lowery had told the board 
members; he was a human being, and the principle of 
nonviolence apphed to all races — and to the state. 

The pardons board had brushed aside evidence 
that Ron had tried to make amends while in prison, 
even saving several lives by reporting plots he had 
overheard to kill people on the outside. The other 
death-row inmates, in fact, considered Ron a 
snitch; once a gang of four attacked him using 
homemade knives and he nearly died from a pene- 
trating chest wound. During one six-year period, 
Ron had refused to emerge from his cell, preferring 
solitary confinement to the dangers he faced out- 
side its doors. Even in his cell, he had to watch out 
for boiling water hurled his way and razorblades 
mounted on sticks pushed through the bars. 

Tangled Legacies 

A few hours after our final visit with Ron, as we 
were returning to witness his execution, we saw an 

ambulance suddenly emerge from the prison com- 
pound and speed toward the freeway. We later 
heard that it had been transporting the widow of 
BUly Watson, the off-duty policeman Ron had shot 
to death in 1976. Mrs. Watson, who had conducted 
an impassioned, 25-year-long campaign to have Ron 
executed, was said to have collapsed an hour before 
the scheduled event. Officer Watson's son, himself a 
police officer, nurtured a different perspecti\e. He 
had once told a reporter, "Hate is not in my vocabu- 
lary. I couldn't hate forever. I don't hate Spivey and I 
don't like the process." 

Shortly before seven, the guards checked our iden- 
tification and waved a metal detector o\'er us before 
we chmbed into a van reser\'ed for Ron's friends and 
sympathizers. Following another securit)' check at 
the prison entrance, we were led to the \isiting area 
where we had said goodbye to Ron a few hours earh- 
er. Posted on the wall were the familiar ground rules 
for \isitors, detailing such instrucrions as ho\\' much 
skin female \isitors could expose (not much) and the 
number of embraces allowed per session (one initial 
and one final). We could hear, but not see, in\ited 
members of the poHtical and law enforcement com- 
munities and other witnesses for the state being 
escorted into a separate room. 

During our vigil, 1 reflected on the stories that Ron 
had revealed to us during three years of monthly 
\'isits and frequent letters. His mother had barely 
attended school, he had told us, and she had taught 
herself to read food orders while working in a restau- 
rant. When Ron turned 16, his parents had ordered 
him to quit school and go to work. His father made 
it clear that his birth had been an accident and that 
he remained unwanted. "He beat me like a dog," Ron 
recalled, "and he talked to me hke one, too." 

Ron ran away several times, and the authorities 
finally remo\'ed him from his home to rescue him 
from his father's abuse. While still a teenager, Ron 
took ad\'antage of a deal to enter the Army rather 
than go to juxenile prison. After he was kicked out of 
the Army for bad behavior, he passed the high school 
equivalency test, but despite his high IQ, he ne\'er 
pursued additional schooling. 

"In all my years in prison and out in society asso- 
ciating with other losers," he wrote us, "I found one 
thing that applied to 100 percent of us: none of us 



had gotten a good education. I feel uncomfortable 
in a room full of well- educated people. So I sought 
out what I considered my own le\'el of society. A 
lack of education forces you to live on the low end 
of all things." 

In the winter of 1976, Ron's wife left hmi, taking 
their one-year old daughter with her. "My world was 
in ruins," Ron told us. "I started drinking to numb 
the pain, and this led to losing a fine franchise busi- 
ness. I took tranquilizers, desperately trying to 
fight off the soul-numbing depression. Three days 
after the loneliest and most miserable Christmas of 
my life, I was taking tranquilizers and drinking all 
day. I had a confrontation with three men in a pool 
hall next to a bar in Macon, Georgia. I just snapped, 
and ended up killing one of the men." Ron then 
drove to Columbus, Georgia, where he tried to hold 
up a bar. He ended up shooting several people and 
killing one of them, Billy Watson. 

"Because I had a gun when I went berserk that 
horrible night, a true American hero lost his life," 
Ron WTOte us. "Officer Billy Watson, a 14-year pohce 
veteran, was moordighting as a security guard at a 
nearby shopping center to earn extra money for his 
wife and children. During that night of madness 

I shot five total strangers, and two died. I caused 
great suffering that night. Since then, my guilt and 
horror have haunted me constantly. Nothing on 
earth — this prison, no one — can punish me like my 
own conscience has done." 

Valley of the Shadows 

Ron's expressions of remorse had not swayed his exe- 
cutioners, who were finally ready to deUver the ulti- 
mate punishment. Minutes before the ritual was to 
begin, we were ushered down a hallway lined with 
motivational posters, including one that featured a 
slightly cross'Cyed, annoyed-looking eagle and the 
admonition to "Focus." Several vans were waiting 
outside, and we climbed into one that had heavy wire 
grillwork behind the dri\'er. Guards locked the door 
from the outside as soon as we entered. 

With us sat Ruth Enero, whom we had met sever- 
al years earlier at a life- issues conference, where my 
wife, Consuelo, had been a speaker. Ruth had been 
flying from California to Georgia to \isit Ron about 
once a year and keeping up a correspondence in 
between, but, as she had said, we could visit him 
more often without ha\ing to travel so far. 



^' 'I 


Throughout much of my life, I had maintained 
a vague interest in understanding what happens 
on death row, beheving that outside authorities 
should monitor conditions there. But I had no 
direct experience with death-row inmates, and I 
had assumed capital punishment to be a routine 
part of the criminal justice system. 

Later on, Amnesty International materials con 
vinced me that execution is more expensive than life 
imprisonment, that there is no e\'idence that it low- 
ers rates of violence, and that its appUcation is enor- 
mously affected by the condemned person's race and 
his access — or lack of it — to competent legal repre- 
sentation. It had come as a surprise to me that the 
United States alone among Western industrialized 
nations still permits the death penalty. 

My wife, by contrast, had a strong history of work- 
ing in life issues and knew exactly where she stood; 
she had once belonged to a group that called itself 
People Against Everything — the death penalty, abor 
tion, war, poverty, euthanasia, racism, and meat con 
sumption. We're both physicians, though, which sets 
our baseline way over on the side of preserving life. 

Rut it was our monthly visits with Ron that 
brought home the futihty and waste of ending the Ufc 
of a man who had sat on death row for more than two 
decades. Ron and I had nearly the same pre-World 
War II birthdate, and both of us were grandfathers. 
Although those who had never met him may have 
hated him, Consuelo and I found his conversation, 

sharpened by years of meditation (death-row inmates 
receive no occupational therapy because they are 
considered temporary), to be compelling and wise. 
We often found it difficult to reconcile the reaht)' of 
the Ron we knew with the knowledge of those five 
hours of madness during which he had destroyed his 
hfe while ending the h\'es of two others. 

As we sat waiting for the final leg of our grim pro 
cession to the death chamber to begin, we watched 
through the window grates as guards ushered peo- 
ple into the other vans. Seven o'clock, the time Ron 
was scheduled to die, came and went, but the vehi 
cles remained motionless. We briefly hoped that the 
delay might mean that the authorities had issued a 
stay, but our hopes were extinguished when the 
\'ans began to crawl around the perimeter of the 
high prison wall, which was topped with coils of 
razor-sharp barbed wire. When we entered through 
a side gate, uniformed officers exchanged passenger 
lists, opened the hood of the van, scanned under 
neath with mirrors, and finally opened a second 
gate. Everyone involved in the ritual had a defined 
and compartmentalized role, which I realized helps 
to contain the emotion attached to executing a 
fellow human being. 

Inside a long, low building, we were led to an 
audience space of perhaps 50 seats installed in grad 
uated rows to afford a clear \iew of the proceedings. 
Through the three -part glass wall we could see Ron 
strapped to a surgical table. His arms were bound to 
armrests extending straight out to the sides, and the 
table was raised 60 degrees to a semi-vertical posi 
tion. With a medical technician on the left and the 
warden standing motionless on the other side, the 
scene reminded me of the crosses at Cal\'ary. 

Ron could see us through the glass partition, and 
we tried to signal our support by raising our brows 
and widening our eyes, in \iolation of the strict 
printed instructions on execution decorum that we 
had signed. He met our eyes, letting us know that he 
appreciated our presence. Other spectators — most 
ly uniformed officers and prison guards — fUed in to 
line the walls on either side of the viewing room. 

The scrub-suited medical technician hovered 
near Ron, monitoring the intra\'enous stand, whose 
infusion line ran to Ron's right arm. A curtain hid 




the people who would be pushing the buttons to 
start the automatic injection of thiopental sodium, 
followed by pancuronium bromide, and finally 
potassium chloride. 

The impeccably dressed warden stood ramrod 
straight as he asked Ron whether he had any last 
words. Ron pulled himself up on his surgical cross. 
"I've apologized to the warden and to the family of 
Mr. Watson," he said, "and I think they know, and I 
hope they believe, that if I had a million lifetimes, I 
could ne\'er say I'm sorry enough." After speaking of 
the failure of the death penalty to recognize the power 
of redemption, Ron ended with, "God has blessed me 
in a miUion ways with people who love me, people I 
love, wonderful people who do good things. I want all 
those that I love and that love me to lca\'e this thing 
tonight without any ugliness, any hatred, any anger, 
any of that, and let Christ be first in their life." 

"It's time," the warden said. "Would you like a 
prayer offered?" The prison chaplain uttered a few- 
words, the warden signaled to the medical techni- 
cian, and the chemicals began to flow. Ron started 
chanting something that sounded like, "Live and 
love!" from behind the glass, but the microphone had 
been turned off and we could hear only with diffi- 
culty. Then suddenly his eyes, still wide open, rolled 
back in his head, and he was silent. I watched with 
medical understanding, knowing that he was not in 
pain, but with that helpless feeUng of having just 
lost a patient. For several minutes, Ron continued to 
breathe. His breaths then resolved into spasmodic 
gasps and his abdominal muscles began to twitch. 
Finally, his chest was completely still. 

Two hapless disciples of Hippocrates, physicians 
from the Medical College of Georgia, appeared from 
the wings with stethoscopes. They listened to Ron's 
chest to ascertain the ab.sence of the same heartbeat 
they had sought to sustain through his diabetes, 
obesity, and mental problems. Now they found it 
stopped, and the curtain was pulled. 

An American Medical Association policy state- 
ment reads, "A physician, as a member of a profession 
dedicated to preserving life when there is hope of 
doing so, should not be a participant in a legally 
authorized execution." According to the newspapers, 
the dean of the Medical College of Georgia had .sent 

a letter to the Department of Corrections withdraw- 
ing the school's support for e\'en this rituaUstic par- 
ticipation in executions, but within a few days, he 
was persuaded to continue. 

States of Grace 

We climbed into the van, w^hich craw^led back to the 
front gate where our car was parked. As soon as the 
van door opened, television crews trained bright 
lights on us and asked for our reactions. I said I was 
glad ior Ron's sake that the electric chair was gone, 
but that I feared for the rest of us that lethal injection 
makes the process too easy. I did not mention that 
the scene I had just witnessed had evoked unsettling 
memories of our visit, several years earlier, to the 
museum of a death camp in Germany where chemi- 
cal execution had been altogether too efficient. 

Two months later, we had a reunion at the home of 
Pat Seaborn, one of Ron's cousins. She showed us the 
shrine in her family room, with Ron's ashes, the size 
14 sneakers we had ordered for him, his glasses, and 
the brown scapular Consuelo had placed around his 
neck during our final visit. Although Ron was not 
Cathohc, he had accepted this token, which is asso- 
ciated with dying in a state of grace, with rehgious 
feeling. He had kissed it after Consuelo's example, 
and the guards had allowed it to remain during his 
execution. We played the tape of his last words, 
which his daughter, Ronnie, hadn't heard, and she 
cried. Ron's granddaughter, who had seen him only 
once, played outside with a friend. 

Pat told us that she and Ronnie had stayed at the 
main gate with the death penalty vigil group until it 
was time to leave. As they drove home, they saw 
clouds in the shape of a group of angels. As they 
watched, they thought they saw a shape come and 
join the other clouds, and then the whole host rose in 
the night sky. I kept thinking that we would see Ron 
again, perhaps somewhere on the road to Emmaus or 
the road to Jackson. The memories of warm conver- 
sations endure. ■ 

Andrew G. Dean '64 retired from the Centers for Disease 
Control and Prevention in 2002 and now teaches and consults 
in public health epidemiology. 



n 33 






n r. "Z 
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D- 1: 





PELICAN BRIEF: While in Florida 
attending an ophthalmology 
meeting, James Brandt '82 
photographed this brown pelican. 
The U.S. Postal Service recently 
turned the image into a commem- 
orative stamp celebrating the 
centennial of the 1 903 creation of 
Florida's Pelican Island Notional 
Wildlife Refuge, the first official 
wildlife refuge in the United States. 
More of Brandt's nature photography 


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